Sample Covid-19 Vaccine Policy Medical Accommodation Form
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In order to provide a safe work environment for employees and workplace visitors, [Employer] implemented a Covid-19 Employer Vaccine Mandate [or Vaccine-or-Test] policy.
[Navigate ongoing return-to-office challenges with the latest policies, employer responsibilities, practical guidance, and more.]
[Employer] is committed to providing equal opportunity and reasonable accommodations to employees with disabilities. [Employer] complies with the Americans with Disabilities Act and all other applicable federal, state, and local laws regarding disability discrimination and accommodation.
[Employer] will engage with employees requesting disability or medical condition-related accommodations regarding the Covid-19 Employer Vaccine Mandate [or Vaccine-or-Test] policy to determine if a reasonable accommodation can be granted. Please provide the following information, which will help to determine possible reasonable accommodations that can be made:
Employee Name:
______________
Date:
______________
Employee’s Department:
______________
Employee’s Supervisor:
______________
What is the expected duration of your disability or medical condition (check below and add description if “other”)?
____ Temporary ____ Long-Term ____ Other: ______________________________________
Briefly describe the disability or medical condition impacted by the Covid-19 Employer Vaccine Mandate [or Vaccine-or-Test] policy:
____________________________________________________
If applicable, please explain how your disability or medical condition prevents you from receiving the Covid-19 vaccine, addressing each type available (Johnson & Johnson, Moderna, and Pfizer).
____________________________________________________
Please include any additional information below and attach any documentation that supports your need for reasonable accommodation (e.g. doctor’s notes).
____________________________________________________
Accommodations suggested by employee (Optional):
____________________________________________________
For how long will requested accommodations be needed (Optional)?
____________________________________________________
I hereby declare that my disability and/or medical condition is impacted by the Covid-19 Employer Vaccine Mandate [or Vaccine-or-Test] policy. I understand that [Employer] isn’t required by law to give me my suggested or preferred accommodation(s) as long as [Employer] provides me with a reasonable accommodation, if possible.
Signed:
______________
Employee’s Name:
______________
Date:
______________