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Workplace Modification Request Form

Request Process

If you are in a higher risk group and want to request a workplace modification related to COVID-19, please complete the Special Request Form below. Individuals who are 65 years of age or older do not have to provide additional medical documentation. Individuals who have an ongoing underlying medical condition will need to provide evidence of their condition. This documentation should be the COVID Medical Verification form and/or any additional medical documents you believe will assist the ADA Coordinator in providing recommended modfications.

*NOTE* Should you have any inquiries related to  workplace modifications, please contact the ADA Compliance Coordinator at




Have you been previously diagnosed with a disability for which you have an active workplace accommodation? *
Please indicate which of the following is related to this request (check all that apply):
Ongoing underlying medical condition: *
By when do these additional modifications need to be implemented? (check all that apply) *

If you are requesting an additional workplace modification based on age alone, press submit now. Your request will be evaluated.

If you are requesting an additional workplace modification based on an ongoing medical condition, please note that once you submit the form, you will receive a confirmation email that will include a COVID-19 Health Care Verification Form. In order for your request to be evaluated, your healthcare provider will need to submit the COVID-19 Health Care Verification form and may provide any additional supporting documentation that they feel will assist in this request.