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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: ____________________________________
click to sign
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Questions to help determine whether an employee and/or minor child in employee’s household has a qualifying
1. Does the employee and/or family member have an underlying health condition that puts them at higher risk for
CoVID-19? Yes No
2. If yes, please describe the underlying health condition.
3. Is the condition permanent? Yes No
4. If not permanent, what is the expected duration of the condition? _____________________________
5. Is this a condition which:
a. Has been identified by the CDC as placing individual at a higher risk? Yes No
b. Continues over an extended period of time? Yes No
c. May cause episodic rather than a continuing period of incapacity? Yes No
d. Requires periodic visits for treatment by a health care provider? Yes No
6. How does this underlying health condition place them at higher risk for CoVID-19 than the general population?
Please explain.
7. Are there any suggested accommodations? If so, please list,
8. In some cases, employees may be able to work at their worksite in an isolated area. If this is available, would you
suggest this as an effective accommodation? Yes No
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Additional Comments:
_______________________________________________ ______________________
Signature of Health Care Provider Date
Return completed form to:
Alief ISD Risk Management Department
Fax Number: 832-678-2446
For Questions or Concerns, please contact the Alief ISD Risk Management Department at
281-498-8110, extension 29146.