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ADA CoVID-19 Related Request for
Accommodation - Medical Certification
The information provided on this form must pertain only to the condition for which the employee is requesting
accommodation under the Americans with Disabilities Act (ADA).
To be completed by Employee
Name: ____________________________________________ Employee ID #: ________________________________
Phone: ______________________________________ Position/Title: _ _____________________________________
Direct Supervisor: ___________________________________ Campus/Department: __________________________
If you are requesting an accommodation because you are the parent/legal guardian of a minor living within the
household, who has an underlying medical condition:
Relationship to you: □ Son □ Daughter (minor child or permanently disabled)
Child(ren)’s Name: ________________________________________________________________________________
By submitting this form to your health care provider, you authorize your provider to release the completed form, which
may contain protected health information (PHI) as defined by HIPAA and similar state and federal laws, to the
administrators of the American's with Disabilities Act at Alief ISD. You may rescind authorization at any time; however,
failure to provide information necessary to evaluate your ADA request, will impact its approval.
Employee Signature: _____________________________________________ Date:
To be completed by the Health Care Provider
Instructions to the Health Care Provider: Please complete and return form via fax to the Alief ISD Risk Management
Dept. at 832-678-2446.
Health Care Provider Name: __________________________________________________________________________
Type of Practice/Specialty: ____________________________________________________________________________
Address: ___________________________________________________________________________________________
Phone Number: _____________________________________ Fax Number: ____________________________________
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