Fill - Free fillable Ontario Tech University COVID-19 Vaccination Accommodation Application PDF form

Ontario Tech University COVID-19 Vaccination Accommodation Application

To protect the health and safety of our community, Ontario Tech University is requiring all employees and students to be fully

vaccinated against COVID-19 prior to coming to campus. Any University Member who cannot be vaccinated for medical reasons

or on grounds protected under the Ontario Human Rights Code may request an accommodation. By submitting this form, you

acknowledge that you are seeking an accommodation to the COVID-19 vaccination requirement.

Complete Section 1 and either Section 2 A or B depending on the accommodation you are seeking.

Completed

Student forms are to be emailed to: Student Accessibility Services

Completed E

mployee forms are to be emailed to: Julie Day, Health and Disability Management Specialist, Human Resources

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CAREFULLY:

• Requests for accommodation will be considered upon completion and presentation of this form.

• To continue to protect the health and safety of the campus community, approved accommodations may include measures other

than the applicant being granted access to campus.

• Individuals with an approved accommodation will be notified in writing through their Ontario Tech University email.

• Decisions will be made consistent with the University’s Accommodation Policy and Respectful Campus Policy

. In the event that

an application is denied, individuals are permitted to reapply if new documentation and/or information becomes available.

• This form only applies to requests for accommodation from Ontario Tech University’s COVID-19 vaccination requirement. If you

are seeking academic or workplace accommodations for other purposes, you will be required to make a separate application in

accordance with existing procedures. If you have a previously approved accommodation, you must still submit this form if you wish

to be considered for a COVID-19 vaccination accommodation.

• Students under the age of 18 must have their parent or legal guardian sign the declaration on their behalf

• Should an outbreak occur, the Durham Region Health Department or Ontario Tech University may impose additional restrictions

or requirements that may not apply to other University members who have been fully vaccinated.

• The applicant may choose to be vaccinated at a later date.

Section 1 – Employee/Student Information (required)

Last Name

First Name

DOB (yyyy/mm/dd)

Home Address

Unit Number

Street Number

Street Name

PO Box

City/Town

Province

Postal Code

Telephone:

Cell Phone:

Banner ID:

Program of Study/Job title

Parent/Guardian Information (required only for students under the age of 18)

Last Name

First Name

Home Address

Unit Number

Street Number

Street Name

PO Box

City/Town

Province

Postal Code

Telephone:

Cell Phone:

Applicant Declaration (required)

I, ,

(Applicant or Parent/Legal Guardian Full Legal Name)

Am the applicant or am the parent/legal guardian of the minor applicant and certify that the information provided on

this application form is accurate and complete as of the date of this submission. I/the minor applicant understand

that knowingly providing false or misleading information on this application form is inconsistent with the

expectations and obligations set forth in the University’s Accommodation Policy and may result in disciplinary

actions being taken against me/the minor applicant under applicable university policies and procedures.

I/the minor applicant confirm that the requirement to obtain COVID-19 Vaccination conflicts with my medical and/or

creed/religious-based needs and am seeking an acc

ommodation from the COVID-19 vaccination requirement on

that basis. I/the minor applicant understand that the University may, at its discretion, approve reasonable

Accommodation Measures under the Accommodation Policy that includes granting a conditional exemption

requiring me to comply with stricter public health and safety measures, including, but not limited to: enhanced

face-masking, rapid-testing, restricted access to campus or facilities, and/or limited participation in certain

programs, activities and events.

By completing section 2A below, I/the minor applicant authorize my licensed medical practitioner to provide the

programs, activities and events.

Ontario Tech University COVID-19 Vaccination Accommodation Application

information contained in this form including if applicable, my permission to disclose the medical condition

necessitating the exemption and, if required, to supply additional information relating to the medical limitation(s)

preventing me from receiving any of the COVID-19 vaccines publicly available in Ontario. This authorization applies

solely for the purposes of the University’s assessment of requests for accommodation associated with the

University’s Mandatory COVID-19 vaccine program. I/the minor applicant agree that this authorization is valid

throughout the duration of my/the minor applicant's request for accommodation and the durations of any

accommodation put in place or any dispute related to this request for accommodation.

Applicant or Parent/Legal Guardian Signature:

Section 2A – Medical Accommodation (to be filled out by the Applicant’s treating medical practitioner)

I, ,

(Name of licensed physician or registered nurse in the extended class)

certify that, due to a medical condition/pregnancy, the named applicant should be exempted from the requirements of Ontario Tech University’s

Mandatory COVID-19 Vaccination Directive, which requires faculty, staff, and students to be vaccinated against COVID-19 with one dose of a

publicly available vaccine by September 3, 2021, and be fully vaccinated by October 17, 2021. I have completed an individual assessment,

considered the Ministry of Health: COVID-19 Vaccination Recommendations for Special Populations and/or the Canada Public Health

Recommendations on the Use of COVID-19 Vaccinations and reviewed risks and benefits with the above-named applicant. The reasons and

anticipated length of accommodation are checked in the boxes below.

Medical

Precautions

Immunity Pregnancy Contraindication Other Length of accommodation

Permanent

Temporary From To

yyyy/mm/dd yyyy/mm/dd

Use this space to provide additional information if necessary and appropriate.

_________________________

_______________________________________________________________________________

Doctor/Nurse Practitioner Information

Last Name

First Name

Business Address

Unit Number

Street Number

Street Name

PO Box

City/Town

Province

Postal Code

Official Stamp

Phone

Ontario Tech University COVID-19 Vaccination Accommodation Application

Section 2B – Creed/Religious Accommodation

Use this space to explain the basis for your creed/religious-based accommodation request. Identify the creed/religion that you belong to, how long

you have been a member of this community of faith and how long you have refrained from receiving vaccinations. Include:

a. what is the sincerely-held creed/religious belief(s) that prevents you from receiving

vaccinations? and;

b. How is the above-noted belief(s) integrally linked to your identity, self-definition and fulfilment

and part of a particular and comprehensive, overarching system of belief that governs your

conduct and practices?

Notice of Collection and Disclosure of Personal Information

Personal information on this form is collected under the authority of the University of Ontario Institute of Technology Act, SO 2002,

c. 8, Sch. O. and will be collected, protected, used, disclosed and retained in compliance with Ontario’s Freedom of Information

and Protection of Privacy Act R.S.O. 1990, c. F.31. This information will be used to administer and enforce the University’s COVID-

19 vaccination program, aimed at decreasing the risk to the health of individuals on campus due to COVID-19.

The

university may disclose this information to Durham College employees who are providing services to the university under an

agreement to share services. This information will be shared only to the extent required to provide the service.

is information will be used and disclosed for these purposes as well as other purposes authorized and required by law, for

example, it may be disclosed to the Chief Medical Officer of Health and Ontario public health units where disclosure is necessary

for a purpose of the Health Protection and Promotion Act or local public health guidelines.

Ques

tions regarding the collection of your personal information may be directed to: Ontario Tech University Access and Privacy

Office, 2000 Simcoe Street North, Oshawa, ON L1H 7K4, 905.721.8668, ext. 6705, email: accessandprivacy@ontariotechu.ca

Notice: Applicants seeking an accommodation from vaccination requirements on the basis of creed/religion may be

required to verify their creed/religion-related needs. In such cases, the University will notify you of the need for

additional or verifying information/documentation prior to granting an accommodation.

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Fillable Ontario Tech University COVID-19 Vaccination Accommodation Application

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