MEDICAL ACCOMMODATION REQUEST FORM
PROCLAMATION 21-14 (VACCINE REQUIREMENT)
The Washington State Department of Transportation (WSDOT) is committed to building an inclusive and welcoming
WSDOT will provide reasonable accommodations to qualified applicants and employees with an underlying medical
condition and/or disability, unless providing such accommodations would pose an undue hardship.
Employee Name: ___________________________________________ EID#:
Regular work schedule: ________________________________________________________
Employee’s Job Title: _____________________________ Region/Division: _________________________
FOR THE HEALTHCARE PROVIDER
Dear Healthcare Provider
Your patient is employed with WSDOT and has disclosed they have a medical condition or disability which may
prevent them from receiving an authorized COVID-19 vaccine.
We are requesting you complete the following form to help us to understand whether your patient has a medical
condition or disability which prevents them from receiving an authorized COVID-19 vaccine.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual.
To comply with this law, we are asking that you not provide any genetic information when responding to this
request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical
history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s
family member sought or received genetic services, and genetic information of a fetus carried by an individual or an
individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services. 29 CFR § 1635.8(b)(1)(i)(B).
1. Are you licensed to practice in the state of Washington?
____ YES ____ NO
2. Describe your professional experience and/or educational background that qualify you to respond to questions
about your patient’s request for a medical accommodation from the COVID-19 vaccination requirement:
3. Your patient has disclosed they have a medical condition or disability that may prevent them from receiving an
authorized COVID-19 vaccine. Does your patient suffer from such a condition?
____ YES ____ NO