COVID-19 Accommodation Request Form (Family Member/Age)

COVID-19 Accommodation Request Form

High-Risk Family/Age-Related Accommodations
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
E-mail*
Work Phone

Area CodePhone Number
Home/Mobile Phone

Area CodePhone Number
Preferred Method of Contact *
Position Information
Department*
Position Title*
Department Director/Chair/ Dean*
Please briefly summarize your current duties or teaching assignment (including current instructional modality):*
Qualifying Condition/Information
Are you requesting an accommodation because you are 65 years of age or older?*

YesNo
Are you requesting modification or accommodation because a member of your immediate household living in same residence are at increased risk, as defined by the CDC, of severe COVID-19 illness?*

YesNo
Name of Doctor*
I certify that my doctor has indicated that a member of my immediate household (defined as anyone maintaining a family relationship living in an employee's home), is: a) at increased risk for COVID-19 complications as defined by the CDC; b) and/or has a disability or health condition, other than those defined by the CDC, which interacts with COVID-19; c) and the family member’s health care provider has advised that the employee modify their work to reduce COVID-19 exposure for that family member. I understand that the University may require doctor certification of this information.*

YesNo
Accommodation Request(s)
If a faculty member or teaching assistant, are you requesting to deliver your assigned courses in online format?*

YesNo
If a staff member or graduate assistant, are you requesting to work remotely from home?*

YesNo
Are you requesting accommodations other than remote work?*

Yes (please describe below)No
If you answered "yes" to the question above, please describe your requested accommodations.
I acknowledge that I am requesting a reasonable accommodation. I agree to fully cooperate with the ADA Office in responding to my request, including providing the appropriate medical documentation, if needed. I understand that I may not be provided with the specific accommodation that I have requested. I verify that the above information is complete and accurate to the best of my knowledge.
Signature*

Clear
I understand this is a legal representation of my signature.
SIU Carbondale provides reasonable accommodations due to COVID-19 to qualified faculty and staff. In general, it is the employee’s responsibility to inform his/her supervisor that he/she needs a COVID-19 related accommodation. A supervisor is not required to consider reasonable accommodations unless the employee states a concern related to the risk of COVID-19 infection. Reasonable accommodations are developed and implemented in a collaborative process among the employee, supervisor and the ADA Office. All medical documentation and information should be shared solely with the ADA Office, not the supervisor.

Contents of this request are confidential and will only be shared as needed with the appropriate personnel to consider the implementation of a reasonable accommodation. This form will not be placed in your employment record file. All medical documentation will be kept confidential.
Should be Empty:

COVID-19 Accommodation Request Form

Personal Information

Position Information

Qualifying Condition/Information

Accommodation Request(s)