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In addition to accommodations provided in accordance with (Transylvania University)

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AccommodationsRequestForm|1
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 hr@transy.edu
• A confidential discussion with human resources is encouraged for employees who are seeking reasonable
accommodations.
• 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 hr@transy.edu.
EMPLOYEE INFORMATION
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.
COVID-19 Alternate Work Arrangement Request Form
AccommodationsRequestForm|2
What specific alternative work arrangements are you requesting? Please select from the options below:
Modification of job duties (provide additional details in the Job Duties and Essential Function
section below).
Modification of work schedule (telework, flexible scheduling, reduction of hours, etc.).
Modification of physical environment (i.e. plexiglass guard, alternative on-site work location).
Leave of absence.
Classroom Reassignment
If the request is other than modification of job duties, please describe specific request based on
the selection above:
Duration requested:
until end of public health emergency per CDC/KDPH or until ________(date)
JOB DUTIES and ESSENTIAL FUNCTIONS
Please describe each of your primary job duties (your direct supervisor will be contacted for the essential
functions of your job):
Which of your duties do you perceive could be performed with
alternative work arrangements, and how?
JUSTIFICATION NARRATIVE
Please describe how the alternative work arrangements requested above will allow you to perform the
essential functions of your position (attach separate sheet if necessary):
CERTIFICATION of HEALTH CARE PROVIDER
Health Care Provider Statement (Provider documentation of CDC/KDPH recognized circumstance or
underlying health condition together with alternative work arrangements suggestions.
Other Supporting Documentation (Record of diagnosis or other supporting documents that meet public
health emergency guidance)
COVID-19 Alternate Work Arrangement Request Form
AccommodationsRequestForm|3
HEALTH CARE PROVIDER CONTACT INFORMATION: The physician may receive communication
from the institution HR requesting information on your impairment/disability and recommendations for
alternative work arrangements. (if request is for health reasons)
Name:
Telephone #:
Fax:
Email Address:
Address:
EMPLOYEE AUTHORIZATION
I authorize a representative of the human resources office to communicate directly with my health care
provider for confirmation of the CDC/KDPH recognized circumstance or underlying health condition and
clarification regarding my need for an alternative work arrangement.
Employee Signature: ________________________ Date: _____________________
EMPLOYEE CERTIFICATION
I certify that the above information is accurate and complete. I understand that I must contact the human
resources office regarding any changes or deviations to this request once submitted.
Employee Signature ____________________ Date ___________________
HUMAN RESOURCES USE ONLY
Required documentation (if applicable) received from employee: No Yes
Re
ceived on date:
Alternative Work Arrangement Decision:
Approved Denied Modified as outlined below:
Notes:
Cabinet Signature (if required):
President Signature (if required):
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In addition to accommodations provided in accordance with (Transylvania University)

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Completed 24 July 2020

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