Request for Extension of COVID-19 Medical Accommodation Form

If you were granted a COVID-19 Medical Accommodation for the Fall 2021 semester and would like an extension of the accommodation for the Spring 2022 semester, you must submit a Request for Extension of COVID-19 Medical Accommodation Form. The university reserves the right to request additional medical documentation in considering the request for extension; however, additional medical documentation may not be required if the medical facts on which your Fall 2021 accommodation was based have not changed.

Upon receiving the completed form (and any requested medical documentation), Human Resources’ Office of Disability Services will consult with your department head/supervisor to determine if the requested extension is reasonable or would result in an undue burden to the university (i.e., significant difficulty or expense). Following consultation with your department head/supervisor, Disability Services will contact you to discuss any questions or concerns raised about your request, and will continue to work with you to address your accommodation needs.

Please note that the fact that you were granted an accommodation in Fall 2021 does not alone entitle you to an accommodation for the Spring 2022 semester. Please contact the Office of Human Resources at employeeaccess@andrew.cmu.edu or 412-268-3930 with questions.

Name:

Email Address:

Phone:

Building Address:

Which program, department, college or school are you associated with?

Has the nature or circumstances of your diagnosis or disability for which you requested an accommodation for the Fall 2021 semester changed? If so, please describe the changes. If not, please answer “N/A.”

By submitting this Request for Extension of COVID-19 Medical Accommodation, I acknowledge and agree:

• Reasonable accommodations are determined, identified and implemented in a collaborative process among myself, my supervisor and the Human Resources’ Office of Disability Services;
• The fact that I was granted an accommodation for the Fall 2021 semester does not entitle me to an accommodation for the Spring 2022 semester;
• I will fully cooperate with Human Resources’ Office of Disability Services in responding to my request, including providing the appropriate medical documentation, if requested;
• Medical information, including the contents of this request, will be kept confidential and only be shared as needed with the appropriate personnel;
• The information I provided on this Request for Extension of COVID-19 Medical Accommodation is complete and accurate to the best of my knowledge.

I agree (required)