Fillable Instructions for USG Reasonable Accommodation Request Form/USG COVID-19 (Middle Georgia State College)

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Instructions for USG Reasonable Accommodation Request Form/USG COVID-19 (Middle Georgia State College)

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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 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 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 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 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 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:
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.
USG COVID-19 Alternate Work Arrangement Request Form
USG Alternative Work Arrangement Request Form| 2
Modification of work schedule (telework, flexible scheduling, reduction of hours, etc.). Please describe:
Duration requested: ___________ until end of public health emergency per CDC/GDPH.
Modification of physical environment (i.e. plexiglass guard, alternative on-site work location). Please
describe:
Duration requested: __________ until end of public health emergency per CDC/GDPH.
Leave of absence: Please describe:
Duration requested: _____________ until end of public health emergency per CDC/GDPH.
Classroom Reassignment. Please describe (include current and desired assignment):
Duration requested:________ until end of public health emergency per CDC/GDPH.
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):
USG COVID-19 Alternate Work Arrangement Request Form
USG Alternative Work Arrangement Request Form | 3
CERTIFICATION of HEALTH CARE PROVIDER
Health Care Provider Statement (Provider documentation of CDC/GDPH 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)
PHYSICIAN CONTACT INFORMATION: The physician may receive communication from the institution
HR requesting information on your impairment/disability and recommendations for alternative work
arrangements.
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 CDC/GDPH 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 office of
Human Resources 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
Received on date: __________
Accommodations Decision: Approved Denied Modified as outlined below:
Name of Institutional Representative: ________________________
Signature of Institutional Representative: ______________________
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Instructions for USG Reasonable Accommodation Request FormUSG COVID-19 (Middle Georgia State College)

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Completed 23 July 2020

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