403.7E2 - Medical Accommodation Request Form - Currently Suspended

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 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

 

This policy was suspended at the January 12, 2022 Board meeting.