Request for Temporary Modified Work Arrangement

Request for Temporary Modified Work Arrangement for Employees at High Risk
Employee Name*
Email*
example@millsaps.edu
Department*
Supervisor Name*
Millsaps College is developing a protocol to accommodate faculty and staff members who may be at higher risk for severe illness from COVID-19. According to the CDC, an individual is at high risk if they meet the following criteria:
- People 65 years and older; or
- People of all ages with underlying medical conditions, particularly if not well controlled including:
  - Cancer
  - Chronic kidney disease
  - Chronic lung diseases, including COPD (chronic obstructive pulmonary disease), asthma (moderate-to-severe), interstitial lung disease, cystic fibrosis, and pulmonary hypertension
  - Dementia or other neurological conditions
  - Diabetes (type 1 or type 2)
  - Down syndrome
  - Heart conditions (such as heart failure, coronary artery disease, cardiomyopathies or hypertension)
  - HIV infection
  - Immunocompromised state (weakened immune system)
  - Liver disease
  - Overweight and obesity
  - Pregnancy
  - Sickle cell disease or thalassemia
  - Smoking, current or former
  - Solid organ or blood stem cell transplant
  - Stroke or cerebrovascular disease, which affects blood flow to the brain
  - Substance use disorders
By submitting this form, I certify that: *

I am at higher risk of severe illness from COVID-19 for one or more of the reasons described above.I live in the same household with a child who is not eligible to be vaccinated with underlying medical conditions. (Working remotely will not normally be considered as a modification option.)
I request the following temporary modified work arrangement. Note: examples of such modifications might include special personal protective equipment, modified workstation or spacing, hybrid work (partial on campus and partial remote), or working only remotely.
I understand that the College is implementing a comprehensive plan to mitigate the risk of
COVID-19, consistent with public health guidance and that;
- Human Resources or other administrators may follow up with me to discuss or clarify my request.
- Not all requests for modified work arrangements will be feasible depending on my position responsibilities and the operational needs of the College.
- If the College determines a modified work arrangement is not feasible, and if my circumstances qualify for Family and Medical Leave (FMLA) under College policy, I will be approved for Family and Medical Leave (FMLA) in accordance with College policy.
- The College is not requiring medical documentation needed to support this request, but reserves the right to request appropriate documentation to support this request in the future.
- Temporary modified work arrangement granted as a result of this request is only in effect during the period that the College determines it necessary under public health guidance on Coronavirus.
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Employee Signature
Date*

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Request for Temporary Modified Work Arrangement for Employees at High Risk