Fillable MEDICAL ACCOMMODATION REQUEST FORM PROCLAMATION 21-14 (VACCINE REQUIREMENT) (Washington)

Fill Online, Printable, Fillable, Blank MEDICAL ACCOMMODATION REQUEST FORM PROCLAMATION 21-14 (VACCINE REQUIREMENT) (Washington) Form

Use Fill to complete blank online WASHINGTON pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MEDICAL ACCOMMODATION REQUEST FORM PROCLAMATION 21-14 (VACCINE REQUIREMENT) (Washington)

On average this form takes 7 minutes to complete

The MEDICAL ACCOMMODATION REQUEST FORM PROCLAMATION 21-14 (VACCINE REQUIREMENT) (Washington) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

BROWSE WASHINGTON FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MEDICAL ACCOMMODATION REQUEST FORM
PROCLAMATION 21-14 (VACCINE REQUIREMENT)
The Washington State Department of Transportation (WSDOT) is committed to building an inclusive and welcoming
work environment.
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
Medical Questionnaire – COVID-19 Vaccination
2
4. If you responded yes to question 3, what is the anticipated duration of the medical condition or disability which
prevents your patient from receiving an authorized COVID-19 vaccination?
____ Permanent ____ Temporary
5. If temporary, provide a timeline when I can expect your patient to be able to receive an authorized COVID-19
vaccination?
6. In your medical opinion, would a leave of absence be effective in allowing your patient to receive an authorized
COVID-19 vaccine so they may return to the full duties of their position at the conclusion of the leave?
____ Permanent ____ Temporary
7. In your medical opinion if a leave of absence is indicated, what is the anticipated duration of leave required that
would permit your patient to be able to receive an authorized COVID-19 vaccine?
I, Dr. _________________________, declare that, in my professional opinion, the above responses are true and
accurate, to the best of my knowledge and ability.
Physician’s Signature___________________________________ Date__________
Printed Physician’s Name _______________________________________________
Please send your response via your patient. We would very much appreciate your response as soon as possible.
WSDOT employees are required to be fully vaccinated with one of the authorized COVID-19 vaccines by October 18,
2021, or have an accommodation in place by October 18, 2021. To avoid delay, if agreeable to you and your patient,
your responses may be emailed to exemption@wsdot.wa.gov
. If you have any questions, please do not hesitate to
contact us at the same email address. Employees may contact their assigned Human Resource Consultant with any
questions.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MEDICAL ACCOMMODATION REQUEST FORM PROCLAMATION 21-14 (VACCINE REQUIREMENT) (Washington)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document