Staff Medical Request for Accommodation – Spring 2021

In preparation for Spring 2021, the University continues to welcome back faculty and staff to campus in a phased approach and in accordance with New York State guidelines, we continue to place the highest priority on the health, safety and well being of campus while ensuring the continuity of the highest standards of work.

If you have your own personal health concern that is listed by the CDC as a COVID-19 concern; please complete this staff form.

Individuals with the following are at HIGH RISK for any age:

• Cancer
• Chronic kidney disease
• COPD (chronic obstructive pulmonary disease)
• Immunocompromised state (weakened immune system) from solid organ transplant
• Obesity (body mass index [BMI] of 30 or higher)
• Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
• Sickle cell disease
• Type 2 diabetes mellitus

Individuals with the following MIGHT BE AT RISK and should contact your medical provider to discuss your medical concern:

• Asthma (moderate-to-severe)
• Cerebrovascular disease (affects blood vessels and blood supply to the brain)
• Cystic fibrosis
• Hypertension or high blood pressure
• Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune
• deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
• Neurologic conditions, such as dementia
• Liver disease
• Pregnancy
• Pulmonary fibrosis (having damaged or scarred lung tissues)
• Smoking
• Thalassemia (a type of blood disorder)
• Type 1 diabetes mellitus

Please note that all responses/information provided in this form are only seen by Human Resources and will be kept confidential.

The responses to this form will be submitted to Human Resources. On submission of the form, your request for accommodation will be evaluated based on justified need, and granted with consideration of equity. For some circumstances, you may be asked by Human Resources to have Certification of Employees Serious Health (WH-380) form completed by your medical provider.

If your request is NOT a result of your own personal health concern please contact your supervisor and if needed Human Resources.

The final decision will be communicated to you by Human Resources.

Human Resources can be reached at clarksonhr@clarkson.edu or 315.268.2222 for questions.

Thank you,

Human Resources