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Medical Accommodation Form

First Name

Last Name

Email address

Cell Phone Number

Department or Job Title

First Scheduled Day of Work

Have you previously submitted a request for accommodation to Westbrook?

Yes No I Don't Know

ATTACHMENTS

As part of the interactive process when someone submits a request for a medical accommodation, we require a note from your medical provider that supports the request. Typically, your medical provider should state in the note that you are under their care and provide us with their instructions about your accommodation request as well as the anticipated duration that the accommodation request is expected to be required. You do not need to include information regarding your specific diagnosis. Please upload that to this page. Incomplete medical accommodation requests will not be considered.

UPLOAD DOCUMENT 1 - jpg, pdf, png, format only

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VERIFICATION AND ACCURACY

I certify and agree that:

The information I am submitting in support of my request for an accommodation is true and accurate. I understand that any intentional misrepresentation contained in this request may result in disciplinary action up to and including termination of employment or the withdrawal of a conditional offer of employment. I also understand that an accommodation may not be granted if it is not reasonable, if it poses a direct threat to the health and/or safety of others in the workplace and/or to me, or if it creates an undue hardship on the Company.

I Agree

Religious Accommodation Form

First Name*

Last Name*

Email address*

Cell Phone Number*

Department or Job Title*

First Scheduled Day of Work*

Have you previously submitted a request for accommodation to Westbrook?*

Yes No I Don't Know

Please identify your sincerely held religious belief, practice, or observance that prevents you from receiving the COVID-19 vaccine.*

Please explain how receiving the COVID-19 vaccine conflicts with your sincerely held religious beliefs, observances or practices.*

Please explain the nature and tenets of your asserted beliefs and provide information about when, where, and how you follow the practice or belief.*

Westbrook may need to obtain additional information and/or documentation about your religious beliefs, observances, or practices. We may need to discuss the nature of your religious accommodation with your religion’s spiritual leader (if applicable) or religious scholars to address your request for an exception. If requested, can you provide documentation to support your belief, observance, or practice and need for an accommodation?*

Yes No

ATTACHEMENTS

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UPLOAD DOCUMENT 2 - jpg, pdf, png, format only

UPLOAD DOCUMENT 3 - jpg, pdf, png, format only

VERIFICATION AND ACCURACY*

I certify that the information I am submitting in support of my request for an accommodation is true and accurate, and that I hold a sincere religious belief that is against the receipt of the COVID-19 vaccination. I understand that any intentional misrepresentation contained in this request and any subsequent submissions related to this request may result in disciplinary action up to and including termination of employment or the withdrawal of a conditional offer of employment. I also understand that my request for a religious accommodation may not be granted if it is not reasonable, if it poses a direct threat to the health and/or safety of others in the workplace and/or to me, or if it creates an undue hardship on the Company.