WCU Documentation of High-Risk Status Form Revised 6/11/2020
To initiate this request, you will need to complete section I below. You will need to have your physician or medical provider complete
section II (section II is not required when age is the primary high-risk factor). Your physician or medical provider will probably ask you to
sign his/her own release form before he/she provides the information requested. Once complete, have your physician or medical provider
mail this form directly to Matt Brown, Director of Benefits, 302 H.F. Robinson Administration Bldg., Western Carolina University,
Cullowhee, NC 28723 or fax to the attention of Matt Brown, fax number (828) 227-7007. Questions may be directed to Matt Brown at
(828) 227-3139 or mbrown@email.wcu.edu.
Appropriate with all data handling procedures, sensitive medical information will be kept in a locked cabinet and electronic
information will be saved to a restricted secure folder. Medical information will be kept confidential and will not be shared with
direct supervisors or colleagues. The requested alternative work arrangement must be discussed to gain the appropriate approval
or to facilitate discussion of alternatives.
SECTION I (Employee Information):
Name: WCU I.D. Number:
Classification / Title: Work Phone Number:
College / Division: Department:
Work Schedule (Days and Hours):
Work Location:
Assistance Request Information (Please attach additional sheets as necessary.)
1. Please specify if this request is related to your health or the health of a household member. Describe the assistance needed.
2. What type of assistance would you recommend? (Please include alternatives.)
Employee Signature: Date:
Release of Information:
I, , hereby authorize the release of the following information to Western Carolina University for
the purpose of determining reasonable assistance.
Signature: Date:
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WCU Documentation of High-Risk Status Form Revised 6/11/2020
SECTION II (To the Diagnosing Professional):
To ensure reasonable and appropriate assistance, employees must provide current documentation of their high risk or vulnerable status
related to COVID-19. The Americans with Disabilities Act identifies a direct threat as an important ADA concept during an influenza
epidemic. Based on guidance of the CDC and the public health authorities as of March 2020, the COVID -19 pandemic meets the direct
threat standard. As the diagnosing professional, you are asked to fully complete all sections of this form. Additional reports can be
attached if necessary. Thank you for your assistance.
I. What is the applicable category of the current CDC guidance of the above condition:
Age 65 years or older
Lives in a nursing home or long-term care facility
People of all ages with underlying medical conditions, particularly if not well controlled, including:
Chronic lung disease or moderate to severe asthmas
Serious heart conditions
Immunocompromised (cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly
controlled HIV or AIDS, prolonged use of corticosteroids and other immune weakening medications)
Severe Obesity (BMI of 40 or higher)
Chronic kidney disease undergoing dialysis
Liver Disease
II. Is this person unable to work on-site due to the current COVID-19 pandemic? Yes No N/A
III. Is this person able to work if working from home is an option? Yes No N/A
IV. Is it necessary that an individual living in the same home with the above individual is unable to work on-site due to the current
COVID 19 pandemic? Yes No N/A
Thank you for your assistance in providing this information so that we may provide services as soon as possible. Please
attach your business card or other form of identification and mail this document to:
Matt Brown, Director of Benefits, 220 H.F. Robinson Bldg., Western Carolina University, Cullowhee, NC 28723
Certifying Qualified Medical Provider/License Number:
Name / Degrees / Title:
Business Address:
Phone Number: E-mail Address:
Medical Provider Signature: Date:
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