403.7E2 Medical Accommodation Request Form - SUSPENDED 1-19-2022

 

MEDICAL ACCOMMODATION REQUEST FORM

  

Date:
Employee Name:
Email Address:
Position/Job Title:
Employee Telephone Number:
Employment Location:

(1) What is the basis for the medical accommodation that you are requesting?

(2) What are you requesting an accommodation from?

 

Item	Yes/No
Vaccination for COVID-19
Testing for COVID-19
Use of Face Coverings

 

 

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Employee Signature                                                    Date

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                                           Office Use

This request has been:

 

______________________________  ________________________________

Approved                                                             Denied

 

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          Administrator                                                                Date