Page 1 of 3 08/21/20 ADA CoVID-19 Related Request for Accommodation - Medical Certification The information provided on this form must pertain only to the condition for which the employee is requesting accommodation under the Americans with Disabilities Act (ADA). To be completed by Employee Name: ____________________________________________ Employee ID #: ________________________________ Phone: ______________________________________ Position/Title: _ _____________________________________ Direct Supervisor: ___________________________________ Campus/Department: __________________________ If you are requesting an accommodation because you are the parent/legal guardian of a minor living within the household, who has an underlying medical condition: Relationship to you: □ Son □ Daughter (minor child or permanently disabled) Child(ren)’s Name: ________________________________________________________________________________ By submitting this form to your health care provider, you authorize your provider to release the completed form, which may contain protected health information (PHI) as defined by HIPAA and similar state and federal laws, to the administrators of the American's with Disabilities Act at Alief ISD. You may rescind authorization at any time; however, failure to provide information necessary to evaluate your ADA request, will impact its approval. Employee Signature: _____________________________________________ Date: To be completed by the Health Care Provider Instructions to the Health Care Provider: Please complete and return form via fax to the Alief ISD Risk Management Dept. at 832-678-2446. Health Care Provider Name: __________________________________________________________________________ Type of Practice/Specialty: ____________________________________________________________________________ Address: ___________________________________________________________________________________________ Phone Number: _____________________________________ Fax Number: ____________________________________