Instructions for USG Reasonable Accommodation Request Form/USG COVID-19 Alternative
Work Arrangement
Fill out applicable request form.
Save the completed form to your computer.
Send the form to the Office of Human Resources using one of the following methods:
o Email the request form as an attachment in an encrypted email to
humanresources@mga.edu (Preferred)
o Print the completed request form and mail the request form to:
Middle Georgia State University
Office of Human Resources
100 University Parkway
Jones Building; Suite 230
Macon, GA 31206
o Fax the request to form to (478) 471-5383
If you need assistance with this process, email humanresources@mga.edu or call (478) 471-
2010.
Human Resources Leave Administrators will confirm with the employee and department when
the request has been processed within OneUSG Connect.
When sending Personally Identifiable Information (PII) through email, encrypting the email is
the most secure way.
To send an encrypted email within Office 365 web outlook.
1. Login to Office 365 using your MGA credentials.
2. Go to Outlook.
3. New Message.
4. When the message box opens up, click on Encrypt.
5. Change permissions.
6. Change permissions to Middle Georgia State University - Confidential
To send an encrypted email within Outlook on your PC.
1. Click on New Email.
2. Go to Options within the new email window.
3. Click on Permissions.
4. Change permissions to Middle Georgia State University - Confidential
USG Reasonable Accommodations Request Form
USG Accommodations Request Form | 1
The University System of Georgia (USG) provides reasonable accommodations for employees with
ADA defined disabilities OR who may be covered by public health emergency guidance when
necessary. A reasonable accommodation is an accommodation that enables the employee to
perform the essential functions of their position, is medically necessary, and does not create an
undue hardship to the institution. Employees who are requesting reasonable accommodation must
complete and submit this request form along with supporting documentation to the Office of
Human Resources at humanresources@mga.edu.
A confidential interactive discussion with Human Resources is encouraged for employees
who are seeking reasonable accommodations.
If more information is needed, the Institution may require that you authorize your health
care provider to confirm your disability and/or the need for the requested
accommodation.
It is your responsibility to ensure that your health care provider statement or other
supporting documentation is returned to the Office of Human Resources.
You are not required to disclose to your immediate supervisor the medical basis for a
requested accommodation. Medical records are confidential and maintained in the Office
of Human Resources only.
To request assistance with the process or form, please contact Vicky Smith, Executive Director of
Human Resources at vicky.smith@mga.edu.
EMPLOYEE INFORMATION
Employee Name: Employee ID #:
Employee Job Title: Employee Department:
Home Phone Number: Cell Phone Number:
E-mail:
Supervisor Name: Supervisor E-mail:
ACCOMMODATION TIMEFRAME
This is a (choose one): New request for accommodations Request for an extension and/or alteration
of existing accommodations*
Physician confirmation may be required.
Anticipated Begin Date of accommodations: __________
Expected end date of accommodations:____________
NATURE OF THE QUALIFYING DISABILITY/PUBLIC HEALTH EMERGENCY (Select all that
apply):
What physical or mental impairment have you been diagnosed with by your physician(s) that require ADA
accommodations?
AND/OR
What underlying medical condition or CDC defined status puts you at a greater risk for severe illness related to
the public health emergency?
USG Reasonable Accommodations Request Form
USG Accommodations Request Form | 2
REQUESTED/SUGGESTED ACCOMMODATION: What Specific accommodation(s) are you requesting?
Please select from the options below:
Modification of job duties. Please describe:
Duration requested:_________ until _________
Modification of work schedule (telework, flexible scheduling, reduction of hours, etc.). Please describe:
Duration requested:_________ until _________
Modification of physical environment (i.e. alternative on-site work location). Please describe:
Duration requested:_________ until _________
Leave of absence or intermittent leave use: Please describe and complete a copy of departmental leave form:
Duration requested:_________ until _________
Assistive equipment. Please describe equipment you are requesting that the Institution provide:
Facilities modification (e.g., doors widened, ramps installed). Please describe:
Interpreter (Sign Language), reader, or real time captioning. Please describe:
Classroom Reassignment. Please describe (include current and desired assignment):
Other Accommodation. Please describe the accommodations you believe are needed to enable you to
perform the essential functions:
USG Reasonable Accommodations Request Form
USG Accommodations Request Form | 3
JOB DUTIES, ESSENTIAL FUNCTIONS, AND ACCESSIBILITY
Please provide a description of your current primary job duties, which of those duties you perceive could be
performed with accommodations, and how. (Please attach additional pages if needed) Essential functions as
outlined in the employee’s official position description and/or from the employee’s supervisor will also be
reviewed. If more specific information is needed to respond to your request, a Job Analysis for your position
may be prepared.
JUSTIFICATION NARRATIVE
Please describe how the accommodation(s) requested above will allow you to perform the essential functions of
your position (attach separate sheet if necessary):
USG Reasonable Accommodations Request Form
USG Accommodations Request Form | 4
HEALTH STATEMENT AND INFORMATION
Health Care Provider Statement (Provider documentation of accommodation requirement or work
arrangement needed)
Other Supporting Documentation (Record of diagnosis or other supporting documents that meets public
health emergency guidance)
PHYSICIAN CONTACT INFORMATION: The physician may receive communication from the
institution’s HR department requesting information on your impairment/disability and recommendations for
accommodations.
Physician’s Name: __________________________
Physician’s Telephone #:______________________
Physician’s Fax #: __________________________
Physician’s Email
Address:__________________________
Physician’s Address:
_________________________________
EMPLOYEE AUTHORIZATION
I authorize a representation of the Office of Human Resources to communicate directly with my health-care
provider for confirmation of the impairment and clarification regarding the need for an accommodation.
Employee Signature: ________________________ Date: __________
EMPLOYEE CERTIFICATION
I certify that the above information is accurate and complete. I understand that I must contact the office of
Human Resources regarding any changes or updates to this request as submitted.
Employee Signature: ________________________ Date: _________
HUMAN RESOURCES USE ONLY
Required documentation (if applicable) received from employee: No Yes Received on date:________
Accommodations Decision: Approved Denied Modified as outlined below:
Name of Institutional Representative: ____________________________
Signature of Institutional Representative: __________________________
June, 2020
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