COVID-19 Pandemic ADA Accommodation Form
I am unable to return to campus to perform my essential job functions due to the
following extenuating circumstances:
• High risk due to age 65 or over
• High risk due to an underlying medical condition(s). Please note that you will need to provide
documentation from your doctor.
• Currently exhibiting COVID-19 symptoms -
• Have been diagnosed with COVID-19 – in isolation
• Have been exposed directly to someone who has been diagnosed with COVID-19 - quarantined
• Caring for an individual who has been diagnosed with COVID-19 – quarantined
• Disability (a physical or mental impairment, which substantially limits one or more major life
activities, (e.g., walking, breathing, sleeping, seeing, hearing, communicating, and other major
life activities). Please note that you will need to provide documentation from your doctor.
Thinking about your job description and job duties, are you able to complete your
essential job functions remotely, and if so, how?
Employee Signature: Date:
Return form to HR with a copy to your Supervisor for review. Please only provide medical
documentation to HR. Since the COVID-19 pandemic is fluid and everchanging, the request is subject
to ongoing review.
Human Resources: Date: