HR - COVID-19 Support Request Form

COVID-19 Spring '22 Transition Support Request
As Illinois adjusts COVID-19 protocols, including the mask mandate, we recognize some employees who are more vulnerable to COVID-19 or those who provide care for family members who are more vulnerable to COVID-19 will seek transition support for the Spring '22 semester. Please use this form to submit your request.
Employee Name *

First Name Last Name
Email *
example@wheaton.edu
Please enter the following: *
I am requesting support due to: *

My own health condition A family member's health condition
Below is a list of conditions that are at an increased risk for COVID-19 severe illness, as outlined by the Centers for Disease Control and Prevention (CDC.) Please check the factor(s) that form the basis of your accommodation request: *

Cancer Chronic Kidney Disease Chronic Liver Disease Chronic Lung Diseases Dementia or other neurological conditions Diabetes (type 1 or type 2) Down Syndrome Heart Conditions HIV Infection Immunocompromised State Mental Health Conditions (mood disorders, including depression, and schizophrenia spectrum) Overweight and Obesity Pregnancy Sickle cell disease or thalassemia Smoking, current or former Solid organ or blood stem cell transplant Stroke or cerebrovascular disease Substance use disorders Tuberculosis
Please describe the support you are seeking: *

Employee signature
I understand that I may need to verify the underlying health condition with Human Resources by providing a statement from an attending physician. I understand that if this is needed, Human Resources will reach out directly to me.
Signature *

Clear
Date

Month Day Year

COVID-19 Spring '22 Transition Support Request