Ferris State University Facial Covering Exemption Request Form
Banner ID
Contact Phone Number
Position Title
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)
acial coverings are in violation of documented industry standards (if so, specify the documented industry standard)
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
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