COVID-19 Alternate Work Arrangement Request Form
In addition to accommodations provided in accordance with the ADA, Transylvania University provides
alternative work arrangements for employees in response to public health emergency guidance when it will
enable the performance of the employee’s essential functions and when doing so does not create an undue
hardship to the university.
Employees who are requesting alternative work arrangements must complete and submit this request form
along with designated supporting documentation to human resources at email@example.com
• A confidential discussion with human resources is encouraged for employees who are seeking reasonable
• If more information is needed, the university may request that you ask your health care provider to
confirm your disability and/or the need for the requested alternative work arrangements.
• It is your responsibility to ensure that your health care provider statement or other supporting
documentation is returned to human resources.
• You are not required to disclose personal health information to your immediate supervisor regarding the
medical basis for a requested alternative work arrangement. Medical records are confidential and
maintained in the human resources office only.
Submit all completed forms to firstname.lastname@example.org.
Employee Name: Employee ID #:
Employee Job Title: Employee Department:
Employee Phone Number: E-mail:
Immediate Supervisor Name: Supervisor E-mail:
Cabinet Member (if different from immediate supervisor):
VOLUNTARY DISCLOSURE OF HEIGHTENED RISK:
What CDC/Kentucky Department of Public Health circumstance or underlying medical condition puts you at a
greater risk for severe illness from the public health emergency?
REQUESTED/SUGGESTED ALTERNATIVE WORK ARRANGEMENTS
This is a (choose one): New request for alternative work arrangement
Request for an extension and/or alteration of existing accommodations.