Return to Campus Accommodation Request Form
Completed forms should be sent to Eva Jackson, Director of Employee Relations at
Marist College is following Dutchess County, the State of New York, Centers for Disease Control and Prevention (CDC)
and Public Health guidelines. The College’s return to work plan protects the health of employees, safeguards the well-
being of the community, and prepares for the eventual return of students and guests to campus. This form may be
updated as guidelines and requirements change.
To be completed by the employee:
Name: ________________________________________________ Job Title:____________________________________
CWID:_________________Employee Phone Number:_________________________________Date: _________________
Supervisor:________________________________________ Line Executive:____________________________________
Department/School: __________________________________Building:________________________________________
Reason for requesting an exception from returning to work on campus:
(please check all that apply)
Ages 65 and older
Living with a family member that is in this age group
Living with a family member that is immunosuppressed
At-risk condition
Living with a family member that has an at-risk condition
Parent/Guardian Exception
Parent/guardian who do not have childcare coverage relative to COVID-19 (e.g. schools, daycares, camps not
open) and have exhausted all other options
Employee serves as the primary caregiver to an adult family member that does not have other care options due
to COVID-19 and have exhausted all other options.
Other - please provide a brief description
All requests will be evaluated and may require additional information and documentation to be approved for a
continued remote work arrangement.
________________________________ _______________________________________
Employee Signature & Date Supervisor Signature & Date
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