Ferris State University Facial Covering Exemption Request Form
N
ame
Banner ID
Contact Phone Number
Position Title
Supervisor
Date
E
xceptions: (Choose one or more, and provide additional detail as necessary at the bottom):
A facial covering in the employee’s work setting is prohibited by law or regulation (if so, specify the law or regulation)
F
acial coverings are in violation of documented industry standards (if so, specify the documented industry standard)
A
facial covering is not advisable due to the employee’s specific health conditions (if so, identify the health condition; a
note, email, or other representation from a health care provider if available would be preferred)
There is a functional, practical reason for the employee to not wear a facial covering in the workplace (if so, identify the
functional, practical reason)
I affirm that the information I have provided on or with this form is true to the best of my knowledge:
Employee digital signature:
Please email this form to HRLeaves@ferris.edu for further review
click to sign
signature
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