UWG COVID-19 Alternate Work Arrangement Request Form - Fall 2020

In addition to accommodations provided in accordance with the ADA, the University of West Georgia (UWG) provides alternative work arrangements for employees in response to public health emergency guidance when it will enable the performance of the employee’s essential functions and when doing so does not create an undue hardship to the institution. Employees who are requesting alternative work arrangements must complete and submit this request form along with designated supporting documentation to the institution’s Office of Human Resources. • A confidential interactive discussion with Human Resources is encouraged for employees who are seeking reasonable accommodations. • If more information is needed, the institution may request that you ask your health care provider to confirm your disability and/or the need for the requested alternative work arrangements. • It is your responsibility to ensure that your health care provider statement or other supporting documentation is returned to the Office of Human Resources. • You are not required to disclose to your immediate supervisor the medical basis for a requested alternative work arrangement. Medical records are confidential and maintained in the Office of Human Resources only. To request assistance with the process or form, please contact COVID-19 Resource line at 678-839-6111 or covid-hr@westga.edu.

Employee ID

Employee Name*

Employee's Job Title*

Employee's Department*

Select

Employee's Home Phone Number

Employee's Cell Phone Number

Employee Email Address*

Supervisor's Name

Supervisor's Email

VOLUNTARY DISCLOSURE OF HEIGHTENED RISK:

What CDC/Georgia Department of Public Health circumstance or underlying medical condition puts you at a greater risk for severe illness from the public health emergency?*

REQUESTED/SUGGESTED ALTERNATIVE WORK ARRANGEMENTS:

What specific alternative work arrangements are you requesting? Please select from the options below:*

You can select more than one option.

Select

Please describe your selection above.*

Please tell us the how long you are requesting the modification.*

JOB DUTIES and ESSENTIAL FUNCTIONS

Please describe each of your primary job duties (your direct supervisor will be contacted for the essential functions of your job):*

Which of your those duties do you perceive could be performed with alternative work arrangements, and how?*

JUSTIFICATION NARRATIVE

Please describe how the alternative work arrangements requested above will allow you to perform the essential functions of your position.

CERTIFICATION of HEALTH CARE PROVIDER

Please select your health care provider information*

Select

PHYSICIAN CONTACT INFORMATION:

Physician's Name

Physicians' Phone Number

Physician's Email Address

Physician's Address

Physician's Fax Number

Employee's Authorization

I authorize a representation of the Office of Human Resources to communicate directly with my health care provider for confirmation of the CDC/GDPH recognized circumstance or underlying health condition and clarification regarding my need for an alternative work arrangement.

Employee's Name

Agreement Date

EMPLOYEE CERTIFICATION

I certify that the above information is accurate and complete. I understand that I must contact the office of Human Resources regarding any changes or deviations to this request once submitted.*

Employee's Name*

Certification Date*

Supporting Documents Upload

Please provide any additional supporting documents.

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