COVID-19 Reasonable Accommodation Request Form

for 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.

If you need to submit medical documentation, please complete the separate COVID-19 Medical Information Request Form as soon as possible after you submit this request.

Name Name * First Last
Date of birth Date of birth * / MM / DD YYYY
Job Title *
Department *
College or School *
Email *
Work phone Work phone * - ### - ### ####
Home phone Home phone * - ### - ### ####
Preferred method of contact *
Dean or Supervisor Dean or Supervisor * First Last
Phone # Phone # * - ### - ### ####
(Please note that while your dean or supervisor will be involved in the process, information about your medical condition, including medical documentation, will not be shared unless authorized by you.)
Please provide details about the essential functions of your job. *
Information About Your Accommodation Request

The Centers for Disease Control (CDC) has identified several groups as those at high-risk for severe illness from COVID-19. Based upon available information to date, those at high-risk for severe illness from COVID-19 include:

People 65 years and older; People with chronic lung disease or moderate to severe asthma; People who have serious heart conditions; People who are immunocompromised; People with severe obesity (body mass index [BMI] of 40 or higher); People with diabetes; People with chronic kidney disease undergoing dialysis; People with liver disease. Please check the CDC website for the latest information about high-risk categories.
Are you requesting an accommodation because you are 65 years old or older and therefore at high risk as defined by the CDC? *

Are you requesting an accommodation because you are 65 years old or older and therefore at high risk as defined by the CDC? Yes No
If your request is based solely on the fact that you are 65 or older, you will NOT be required to submit the Medical Information Request form.
What is the underlying condition for which you are requesting an accommodation?

What is the underlying condition for which you are requesting an accommodation? Serious heart condition Chronic lung disease/moderate to severe asthma Diabetes Severe obesity (BMI ≥40) Chronic kidney disease undergoing dialysis Immunocompromised Liver disease Family member with a condition at high risk for serious illness Other Other
Is your condition temporary, permanent, or unknown? *
If the condition is temporary, what is the anticipated date you will no longer need the accommodation(s)? If the condition is temporary, what is the anticipated date you will no longer need the accommodation(s)? / MM / DD YYYY
Are you requesting to work remotely?

Are you requesting to work remotely? Yes No
Anticipated Return to Campus Date: Anticipated Return to Campus Date: * / MM / DD YYYY
If not requesting to work remotely, what accommodation(s) are you requesting and how will they assist you in performing the essential functions of your job? *
This is to acknowledge that I am requesting a reasonable accommodation. I agree to fully cooperate with the EEOO 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. *

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.
Vanderbilt provides reasonable accommodations due to COVID-19 to qualified employees. 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 provide reasonable accommodations if he/she is not aware of the employee’s need and desire for the accommodation. Reasonable accommodations are determined, identified and implemented in a collaborative process among the employee, supervisor and the Equal Employment Opportunity Office (EEOO). All medical documentation and information should be shared solely with EEOO, 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.

COVID-19 Reasonable Accommodation Request Form

COVID-19 Reasonable Accommodation Request Form

Information About Your Accommodation Request