Faculty/Staff Self|Identification Form

Drew 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 this form.

Faculty/Staff *

Faculty

Staff

First Name *

Last Name *

Job Title *

Department *

Email *

Phone *

Preferred method of contact *

Dean or Supervisor *

(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.)

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? *

Yes

No

What is the underlying condition for which you are requesting an accommodation (please check all that apply)?

Serious heart condition

Chronic lung disease/moderate to severe asthma

Diabetes

Severe obesity (BMI ≥40)

Chronic kidney disease undergoing dialysis

Immunocompromised

Liver disease

OtherOther

If Other, please describe nature of medical condition.

Are you requesting a temporary work modification because you are the primary caregiver for a member of your household, or the primary caregiver for a family member who lives elsewhere, who falls into one of the categories identified by the CDC as being at high risk for severe illness from COVID-19? *

Yes

No

Is your condition temporary, permanent, or unknown? *

What accommodations are you seeking? *

All employees will need to wear a face covering on campus. If you are designated as an On-Site Employee or Modified Virtual Employee and cannot wear a face covering at all, and thus will need to work remotely, please check this box.

Radio Button

Option 1

Option 2

Digital Signature

This is to acknowledge that I am requesting a reasonable accommodation. I agree to fully cooperate with the Office of Human Resources 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 certify that the above information is complete, true, and accurate to the best of my knowledge. *

Enter Name Here

Drew provides reasonable accommodations due to COVID-19 to qualified employees. In general, it is the employee’s responsibility to inform the Office of Human Resources of the need for a COVID-19 related accommodation. The Office of Human Resources is not required to provide reasonable accommodations if it is not aware of the employee’s need and desire for the accommodation. Reasonable accommodations are determined, identified and implemented in an interactive process with the employee, supervisor and the Office of Human Resources. All medical documentation and information should be shared solely with the Office of Human Resources, 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.

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