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 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
(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.)
Dean or Supervisor Dean or Supervisor First Last
Phone # Phone # - ### - ### ####
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 increased risk for severe illness from COVID-19. Based upon available information to date, those at increased risk for severe illness from COVID-19 include:
People with cancer, 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; People with Chronic obstructive pulmonary disease; People with cerebrovascular disease; People with cystic fibrosis; People with hypertension; People with neurologic conditions such as dementia; People who are pregnant; People with pulmonary thrombosis; People who smoke; People with thalassemia. Please check the CDC website @ https://www.cdc.gov/ for the latest information about high-risk categories.
Are you requesting an accommodation because you are at increased risk as defined by the CDC?

Are you requesting an accommodation because you are at increased risk as defined by the CDC? Yes No
If your request is not based on your own personal health condition, please direct your request to:
FACULTY REQUESTS– Dean of your school; STAFF REQUESTS – click here
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/damage Diabetes Cancer Severe obesity (BMI ≥40) Chronic kidney disease undergoing dialysis Immunocompromised Sickle Cell disease Liver disease Hypertension or high blood pressure Cerebrovascular disease Cystic fibrosis Neurologic condition Pregnancy Smoking Thalassemia Moderate to severe asthma COPD Pulmonary thrombosis Other Other
Are you requesting to work remotely?

Are you requesting to work remotely? Yes No
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?
Is your condition temporary, permanent, or unknown?

Is your condition temporary, permanent, or unknown? Temporary Permanent 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
This is to acknowledge that I am requesting a reasonable accommodation. I agree to fully cooperate with the Equal Opportunity and Access Office (EOA) 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.
To initiate your request for an accommodation, send to EOA via direct submission, fax to (615) 343-4709, or email to EOA@vanderbilt.edu. If you are required to submit medical documentation, please complete the separate COVID-19 Medical Information Request Form and send to EOA as soon as possible after you submit this request.

Vanderbilt provides reasonable accommodations due to COVID-19 to qualified employees. In general, it is the employee’s responsibility to inform their supervisor that they need a COVID-19 related accommodation. A supervisor is not required to provide reasonable accommodations if the supervisor 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, the supervisor, and EOA. All medical documentation and information should be shared solely with EOA, not the supervisor.

Contents of this request are confidential and will only be shared as needed with the appropriate personnel for consideration and, as appropriate, 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