USG COVID-19 Alternate Work Arrangement Request Form
USG Alternative Work Arrangement Request Form | 1
In addition to accommodations provided in accordance with the ADA, the University
System of Georgia (USG) 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 institution.
Employees who are requesting alternative work arrangements must complete and submit
this request form along with designated supporting documentation to the institution’s
Office of Human Resources at firstname.lastname@example.org.
A confidential interactive discussion with Human Resources is encouraged for
employees who are seeking reasonable accommodations.
If more information is needed, the institution may request that you ask your health care
provider to confirm your disability and/or the need for the requested alternative work
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 alternative work arrangement. 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 email@example.com.
Employee Name: Employee ID #:
Employee Job Title: Employee Department:
Home Phone Number: Cell Phone Number: E-mail:
Supervisor Name: Supervisor E-mail:
VOLUNTARY DISCLOSURE OF HEIGHTENED RISK:
What CDC/Georgia 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:
What specific alternative work arrangements are you requesting? Please select from the options below:
Modification of job duties. Please describe:
Duration requested: ___________ until end of public health emergency per CDC/GDPH.