Practical Guidance

Sample Covid-19 Vaccine Policy Medical Accommodation Form

April 11, 2022
Sample Covid-19 Vaccine Policy Medical Accommodation Form

[Bloomberg Law subscribers can access the annotated version of this policy template with expert commentary and analysis. Not a subscriber? Request a demo.]

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.

[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:

______________

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