403.7E2 - 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

 

___________________________________  ________________________________

Employee Signature  Date

Office Use

This request has been:

______________________________  ________________________________

Approved  Denied

_________________________________________  ______________________________

Administrator  Date