Covid-19 Accommodation Request Form

Siena Heights 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.

Accommodations will only be made for those students or employees (or employees with family members) with verified health issues as defined by the CDC guidelines. Additionally, the University cannot guarantee that it will implement all requested accommodations and may implement alternative accommodations that meet CDC, MIOSHA, Governor’s Executive Orders, or Lenawee Health Department regulations.

Please Note: While your division chair or supervisor will be involved in the process, information about your medical condition, including medical documentation, will not be shared unless authorized by you.

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.

* Required Fields.

Covid-19 Accommodation Request Form
Who Are You?*
Preferred Method of Contact*
Are you requesting an accommodation because you are 65 years old or older and therefore at high risk as defined by the CDC?*
What is the underlying condition for which you are requesting an accommodation? Please check all that apply.*
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?*
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 will need to work remotely, then please check the box below.

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