COVID-19 return to in-person work exception request form
Name
Banner ID
Phone Number
Position Title
Supervisor
Please select one of the following options
.
I am
subject to a Federal, State, or Local quarantine or isolation order related to COVID-19
. I am experiencing COVID-19 symptoms and seeking a medical diagnosis
. I have been advised by a health care provider to self-quarantine related to COVID-19
. I am caring for my child whose school or place of care is closed due to COVID-19
. I am caring for individual subject to a quarantine or self-quarantine as described above
. I have disability that puts me at higher risk for COVID-19 or otherwise prevents me from performing my essential
duties
. I have a non-disability related condition that puts me at higher risk for COVID-19 (if this option is selected,
please provide a specific reason as to why you are unable to return to work in the box below)
.
Other reason not listed (if this option is selected, please provide a specific reason as to why you are unable to
return to work in the box below)
Please email this form to HRLeaves@ferris.edu for further review
