EIU Request for COVID-19 Reasonable Accommodation for Remote Work due to Medical Condition and inability to be vaccinated

As the State of Illinois is in Phase 5 Reopening of its COVID-19 response and vaccines are readily accessible and available, it is the policy of EIU to return to normal operations. This temporary policy will be in effect until July 27, 2022.

This remote work accommodation is based on an employee’s medical condition and inability to be vaccinated. This potential accommodation cannot be provided to any employee based on an immediate family illness or medical concern.

All COVID-19 remote work accommodations will be evaluated every two months and may be cancelled by EIU, at its discretion, based on guidance from IBHE, IDPH and/or the CDC, or an employee’s inability to perform essential functions of the position remotely (including availability in Charleston, IL during regular office hours and accurate time reporting). Upon submission of this form, Human Resources will begin an interactive process with the employee, his/her supervisor and relevant Vice President to determine if a reasonable accommodation based on medical documentation and program and/or office need may be made.

This form should be completed when an employee has indicated their desire to request a reasonable accommodation from EIU due to their own (i) medical condition being identified by the CDC as one that “can make them more likely to get severely ill from COVID-19” and (ii) their inability to be vaccinated based on a medical opinion or religious beliefs. The CDC has outlined the conditions that would qualify for a remote work accommodation here.
If you are claiming a religious exemption, you MUST fill out these forms and upload them with this form.

Upon completion, this form must be sent to the ADA Coordinator at lcholloway2@eiu.edu.

Reasonable accommodations may include full-time remote work assignment, partial remote work assignments, staggered start/end times, etc.

To be considered, the employee will need to provide current documentation from their physician, a copy of their job description, and a statement of the requested accommodation.

Once documentation is received, an interactive discussion will occur with the employee, their supervisor, Vice President and the ADA Coordinator. It should not be assumed that a request is acceptance and that remote work is available. Independent of the individual requesting the accommodation, EIU will determine availability of remote work based on the position description and Departmental needs.

Following any medical accommodation for full remote work, an employee will need to provide a medical release before resuming professional responsibilities on-campus.
Name Name * First Last
E# *
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email *
Phone Phone * - ### - ### ####
Supervisor *
Department *
Requested Begin Date Requested Begin Date * / MM / DD YYYY
Documentation

Acceptable documentation must be from a medical provider on his/her official letterhead; must be dated; must contain the name of the provider in legible printed format along with signature; and must include the COVID-19 medical condition as identified by CDC to support the request as well as the provider’s opinion of why you cannot be vaccinated.*

*As to the provider’s opinion of inability to be vaccinated, this is not required if you are asserting an exemption for religious beliefs.
Please upload documentation from a treating medical provider for the condition that supports the basis for your request (should be a medical condition identified under CDC guidelines provided in the above link)*

Upload Documentation *

Attach Files
Identify the names and addresses of physicians, therapists, psychologists or other health care providers who have information or documentation concerning the condition for which you seek accommodations. *
I hereby authorize the above-listed health care provider and any others who have treated me to release to EIU all medical records concerning my condition disclosed herein and provide any opinions to EIU concerning my ability to be vaccinated and perform job-related functions with or without reasonable remote work accommodations. *

I hereby authorize the above-listed health care provider and any others who have treated me to release to EIU all medical records concerning my condition disclosed herein and provide any opinions to EIU concerning my ability to be vaccinated and perform job-related functions with or without reasonable remote work accommodations. Yes No
Identify and describe why you are unable to perform your position on campus – either full-time or part-time, or other accommodations that you are requesting. ** *
Upload Your Job Description *

Attach Files
Upload the Religious Accommodation As Inability To Be Vaccinated Against COVID-19
Request Form For Remote Work And Authorization to Release Immunization Records

Attach Files
Signature
I certify that I have read and reviewed the job description for my job or position and am informed of the essential functions of my job. I further certify that the foregoing statements are complete, accurate and true to the best of my knowledge, and I understand that a misstatement or omission of fact may be cause for disciplinary action.*

Draw or Type *

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.
Print name as signed above.*
Date Submitted Date Submitted * / MM / DD YYYY

EIU Request for COVID-19 Reasonable Accommodation for Remote Work due to Medical Condition and inability to be vaccinated

EIU Request for COVID-19 Reasonable Accommodation for Remote Work due to Medical Condition and inability to be vaccinated

Documentation