COVID-19 Medical Information Request Form

for Medical Providers of Vanderbilt Faculty, Staff, and Other Employees

Vanderbilt University’s response to the COVID-19 pandemic is designed to sustain our important mission of education and research while maintaining the health and safety of our faculty, students and staff.

Faculty or staff whose age or health condition falls within one of the CDC High Risk Categories or who have other special circumstances may seek a workplace adjustment through the reasonable accommodation process by utilizing these forms.

Prior to completing this form -- have your healthcare provider complete this form and return to you.

Attach it below

Physician/Health care provider document

Attach Files
Name Name First Last
Email
Job Title
College or School
Department
Dean or Supervisor
Release of Information
I hereby authorize the release of the following information to Vanderbilt for the purpose of determining the availability of reasonable work place accommodations. I further authorize Vanderbilt to seek clarification of this documentation,if necessary, by contacting my physician or health care provider.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

COVID-19 Medical Information Request Form

COVID-19 Medical Information Request Form

Release of Information