COVID 19 Temporary Adjustment Request Form Fall 2020

Please provide your Full Name, Date of Birth, and BlazerID.(*)

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Please provide a phone number where you can be reached. (*)

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Please select the reason for your request that applies to you or your situation. (*)

I am 65 or older

My medical provider has determined that I am an individual who is considered high risk according to Centers for Disease Control and Prevention. Please describe the specific nature of your request.

I reside with or care for someone (in a non-health care setting) who is considered a high risk individual. If caring for someone, please describe in detail in what capacity you are caring for this individual.

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Date of Birth

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If you selected the third option for #3, please describe in detail in what capacity you are caring for this individual.

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Please identify the specific temporary adjustment you are requesting. Adjustments may include, for example: access to remote instruction, exemption from on-campus attendance, other. Include any additional adjustment that has not been addressed above and the rationale for the additional request.(*)

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I hereby attest that I meet one of the following conditions for which I am requesting a COVID-19 related temporary adjustment. I hereby attest to the fact the information is accurate and truthful. I am an individual who is considered a higher risk for severe illness per the Centers for Disease Control and Prevention, and I require a temporary adjustment. -I permanently reside with or care for someone (in a non-health care setting) who is considered a high risk individual due to COVID-19, and I require a temporary adjustment. I acknowledge that UAB Disability Support Services reserves the right to request medical documentation related to the circumstance I selected above and that I must provide such documentation if requested in order to receive a temporary adjustment related to COVID-19. I acknowledge that approved temporary adjustments are valid only during the time period determined by UAB Disability Support Services as indicated on the Notice of Temporary Adjustment. I acknowledge that I am requesting a temporary adjustment related to COVID-19. I acknowledge that if I wish to register with Disability Support Services in addition to requesting a temporary adjustment, I must follow DSS's eligibility determination process. (*)

I agree with the statement above

I do not agree with the statement above

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Are you a robot, Blazer?(*)

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Submit

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COVID 19 Temporary Adjustment Request Form Fall 2020