COVID-19 Pandemic ADA Accommodation Form
Name:
Department:
Supervisor:
I am unable to return to campus to perform my essential job functions due to the
following extenuating circumstances:
Examples are:
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 -
quarantined
Have been diagnosed with COVID-19in 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-19quarantined
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.
Other
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.
Approved
Denied
Supervisor: Date:
Human Resources: Date:
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