[Company Name] is committed to providing equal employment opportunities without regard to any protected status, and a work environment that is free of unlawful harassment, discrimination, and retaliation. As such, [Company Name] complies with all laws protecting employees with disabilities or medical conditions. [Company Name] will provide reasonable accommodations for any known medical condition or disability that prevents an employee from getting vaccinated for COVID-19, as long as the requested accommodation does not create an undue hardship for [Company Name] or pose a direct threat to you or others in the workplace. 
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To request an accommodation related to [Company Name]’s COVID-19 Vaccination Policy, please complete Part 1 of this form, have your medical provider complete Part 2 (the certification portion), and return them to Human Resources. This information will be used by Human Resources or other appropriate personnel to engage in an interactive process to determine the precise limitations of your ability to comply with [Company Name]’s COVID-19 Vaccination Policy and explore potential reasonable accommodations that could overcome those limitations. Refusing to provide the information requested in these forms may impact [Company Name]’s ability to adequately understand your request or effectively engage in the interactive process to identify possible accommodations.  
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[Company Name] makes determinations about requested accommodations and exemptions on a case-by-case basis, considering various factors and based on an individualized assessment in each situation. [Company Name] strives to make these determinations expeditiously and in a fair and nondiscriminatory manner and will inform you after we make a determination. If you have any questions about an accommodation or exemption request you made, please contact [Name] in the Human Resources Department.

Part 1 - To be completed by employee requesting accommodation 

• Employee Name:
• Employee ID:
• Job Title:
  
• Location:
  
• Department:
  
• Supervisor:
  
• Phone Number:
  
• Email Address:
  

• ⃞  I am requesting a medical exemption / accommodation to the requirement for COVID-19 vaccination.
• ⃞  I understand that the certification must be signed by a licensed physician (MD or DO), nurse practitioner (NP), or physician’s assistant (PA).
  
• ⃞  Please describe the specific reasonable accommodation you are requesting from [Company Name].
  

EMPLOYEE ACKNOWLEDGEMENT

I verify that the information I am submitting in support of my request for an accommodation is complete and accurate to the best of my knowledge, and I understand that any intentional misrepresentation contained in this request may result in discipline, up to and including termination. [While my request is pending, I understand that I must comply with [Company Name]’s workplace safety standards (e.g. face coverings, regular COVID-19 testing) for unvaccinated or not fully vaccinated individuals as a condition of my employment.] I also understand that my request for an accommodation may not be granted if it is not reasonable, if it poses a direct threat to the health and/or safety of others in the workplace and/or to me, or if it creates an undue hardship on [Company Name].

Signature: 
Date:
Print Name:

Part 2 - To be completed by Employee's Medical Provider

• employee name:
• Employee ID:
  
• Company Name:
  

NOTIFICATION TO THE CERTIFYING MEDICAL PROVIDER

[Company Name] requires a COVID-19 vaccination as a condition of employment. The above-named employee is requesting an exemption from this vaccination policy. Accommodations to the COVID-19 Vaccination Policy may be allowed for certain recognized contraindications. Should you have any questions, please contact [Company Name representative] at [Company Name representative’s contact information]. Thank you.
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• ⃞  I certify that the person requesting this certification has a medical condition that contraindicates them from receiving any of the available FDA-authorized COVID-19 vaccinations.

Please check the appropriate box and describe below:
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• ⃞  The person requesting this certification has an applicable CDC-recognized contraindication to this vaccine.
• ⃞  There is an applicable manufacturer’s vaccine insert contraindication to this vaccine.
• ⃞  The person requesting this certification has a physical condition or medical circumstance such that immunization is not considered safe.
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• *REQUIRED: Describe the contraindication, physical condition, or medical circumstance meeting the criteria above:

The contraindication, physical condition, or circumstance is: 
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• ⃞  Long-term 
  
• ⃞  Temporary
• If this is a temporary condition or medical circumstance, indicate when it is expected to end or expire (allowing for COVID-19 vaccination to begin after the date provided):
  
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• Medical Provider Signature:
• Date:
• Print Name:
• Address:
  
• Phone number:
  

Part 3 - To be completed by Human Resources Representative

• Date this request form was received in Human Resources:
• Interactive discussion date(s) if applicable: 
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• Accommodation granted?
  YES
  NO
  
• Describe Accommodation:
  
  
  
• If Accommodation is granted, list required alternative safety precautions required: 
  
  
  
• If Accommodation is not granted, explain why: 
  
  
  
• Name of Representative:
  
• Signature of Representative:
  
• Date: