Sample Employee Accommodation Request

Modified on Wed, 26 Jan 2022 at 11:38 AM

Sample COVID-19 Accommodation Documents


Medical Accommodation Request Form

COVID-19 Specific

To be completed by Health Care Provider:



Healthcare Provider Name:        ______________________________________________________________

Healthcare Provider Address:        ______________________________________________________________

Health Care Provider Phone:         _______________________________ Fax:___________________________

Health Care Provider Email:         _________________________________@___________________________

Healthcare Provider Area of Practice:    ______________________________________________________________

Employee (Patient) Name:         ______________________________________________________________

Employee’s Position:            ______________________________________________________________

Employee Email:            _________________________________@___________________________

State Where Employed:             _______________________    Job Title:____________________________


Our employee listed above (your patient) has requested an accommodation for his/her position at COMPANY NAME (the “Company") related to COVID-19 or the vaccine. 


We are requesting you to provide feedback to the questions below based on your medical expertise and knowledge of your patient so we can evaluate his/her/their request for a COVID-19-related accommodation. Feel free to include a more detailed narrative response to any and all questions if needed to answer more fully.  Please return the completed questionnaire to your patient as soon as possible as we have requested s/he/they return it to us within 5 business days.


Please limit your responses to a description of your patient’s medical condition as it relates to COVID-19 or the vaccine. Please do not provide the details of your diagnosis of the patient.  Also, please do not provide any “genetic information,” which includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or an individual’s family member receiving assistive reproductive services. 


Thank you for your anticipated cooperation. This information will be kept separate from your patient’s personnel file.


EMPLOYEE: RETURN COMPLETED FORM TO:

[HUMAN RESOURCES OR PERSONNEL DEPT OR DESIGNEE].

ALONG WITH A COPY OF THE ATTACHED AUTHORIZATION/RELEASE

FULLY COMPLETED AND SIGNED BY YOU THE EMPLOYEE

****



Medical Accommodation Request Form

COVID-19 Specific

(To be completed by Health Care Provider)



Patient (Employee) Name: ________________________________________________________  

Please review the employee’s (patient’s) position and activities (if applicable) with him/her/them to determine your answers to these questions to help the Company determine accommodation options.


Is the employee fully vaccinated against COVID-19?     ☐  Yes         ☐  No

Does the patient have a physical or mental impairment that prevents him/her/they from getting the COVID-19 vaccination (hereafter “employee’s impairment”)?     ☐  Yes         ☐  No

If yes, please identify the employee’s impairment(s): __________________________________________________________________________________________________________________________________________________________________________

Does the patient have a physical or mental impairment that prevents him/her/they from undertaking infection prevention measures related to COVID-19 (hereafter “employee’s impairment”) such as masking or regular testing?     ☐  Yes         ☐  No

If yes, please identify the employee’s impairment(s): __________________________________________________________________________________________________________________________________________________________________________

If yes to 2 or 3 above, when did the symptoms of the employee’s impairment(s) first appear? _______________

What is the duration or expected duration of the employee’s impairment(s)?

Identify Duration:

________ # of days    ________ # of weeks    ________ # of months    ______ Permanent

________ Indefinite/Cannot determine at this time

When is the next scheduled evaluation/examination? _______________________________________

Based on the Company’s COVID-19-related requirements, does/do the employee’s impairment(s) substantially limit his/her/their ability to perform the essential functions of employee’s position?

 ☐  Yes     ☐  No

If yes, which functions are limited and what are his/her work restrictions? _________________ ______________________________________________________________________________

In what way does the employee’s impairment limit his/her ability to perform these functions?

______________________________________________________________________________

______________________________________________________________________________


How long will he/she/they be limited in performing these functions?

________ # of days    ________ # of weeks    ________ # of months    ______ Permanently

________ Indefinitely/Cannot determine at this time

What accommodation(s), if any, would enable the employee to comply with the essential functions of the position that would require the employee to be vaccinated or employ infection prevention measures such as masking or regular testing?

Identify accommodation(s): _____________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

How long would that accommodation be needed?    

    _______ # of days    ________ # of weeks    ________ # of months    ______ Permanently

________ Indefinitely/Cannot determine at this time

Would receiving a COVID-19 vaccination result in a direct safety or health threat to this employee or other people (co-workers, members of the general public, etc.)?     ☐  Yes     ☐  No

If yes, please describe:

Which job functions(s) would pose such a threat? _____________________________________

______________________________________________________________________________

What is the direct safety or health threat(s) posed? ____________________________________

______________________________________________________________________________

What, if any, accommodation(s) would eliminate the direct safety or health threat or reduce it to an acceptable level? _________________________________________________________________

_______________________________________________________________________________

How long would performing these job functions result in a direct safety or health threat to this employee or other people?

________ # of days    ________ # of weeks    ________ # of months    ______ Permanently

________ Indefinitely/Cannot determine at this time

Please provide any additional comments or suggestions material to this request for accommodation.

____________________________________________________________________________________

____________________________________________________________________________________


Health Care Provider:    _________________________________________________    ____________________

            Signature                                   Date

_________________________________________________    ____________________

            Printed Name                                   State License No.    



EMPLOYEE: WHEN YOU RETURN THE COMPLETED FORM PLEASE INCLUDE A FULLY COMPLETED AND SIGNED COPY OF THE ATTACHED AUTHORIZATION/RELEASE

***


Medical Authorization/Release Form

COVID-19 Specific

(To be completed by the Employee)

TO:

Healthcare Provider Name:        ______________________________________________________________

Healthcare Provider Address:        ______________________________________________________________

______________________________________________________________

Health Care Provider Phone:         _______________________________ Fax:___________________________

Health Care Provider Email:         _________________________________@____________________________


I authorize and request the disclosure of protected information for the purpose of review and evaluation in connection with my request for a medical accommodation from my employer, COMPANY NAME (the “Company”), related to COVID-19 and/or the vaccine. I expressly request that your designated record custodian disclose and release medical information related to this limited inquiry, such as my diagnosis and, including but not limited to any and all contraindications for the COVID-19 vaccine, or COVID-19 infection prevention measures to:


    The Company and/or its representatives, including CareValidate (contact Julie Bordo at email:     julie@carevalidate.com) using a secure link/portal they provide.


Your response should be limited. Please refrain from sending your complete medical records or providing any medical information unrelated to the exemption request and the need for accommodation. Additionally, the Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic information," as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.


I understand,


(1) I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization. 

(2) the information released in response to this authorization may be re-disclosed to other parties. 

(3) this authorization shall be in force and effect until two years from date of execution at which time this authorization expires. 

(4) This information will be kept separate from my personnel file.


I agree that a copy (digital or paper) or facsimile of this Authorization may be treated as a signed original.


In order to timely review my accommodation request, please provide the requested information within five (5) business days. Thank you. 


Employee (Patient) Name: ___________________________________________________________________________


Employee (Patient) Signature: ________________________________________________________________________


Employee (Patient) Date of Birth:_________________________        Date:__________________________

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