Bluecrew COVID-19 Religious Accommodation Request Form

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Individuals applying for employment and employees with Bluecrew may request reasonable accommodation under the Americans with Disabilities Act of 1990 (ADA), the ADA Amendments Act of 2008 (ADAAA), Title VII Civil Rights Act, and USERRA and are encouraged to complete this form in its entirety PRIOR to accepting jobs with our clients that describe functions and duties bringing up your need for adjustment, change or assistance. If the individual is unable to complete this form on his or her own, another person may complete the form on the inquiring individual's behalf. All ADA medical-related information is considered confidential and is not a part of an employee’s personnel file. Each request is considered on a case-by-case and confidential basis.

Requestor's Legal Name *

Requestor is which of the following? *

Applicant with Bluecrew

Active Employee with Bluecrew

Former Employee with Bluecrew

Other (describe relationship):

Requestor's Phone Number(s): *

Requestor's Email Address *

Is this a medical accommodation or another type of accommodation, such as religious or military?

Medical

Religious

Military

Other:

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If this is a non-medical accommodation, please describe your request.

List the job positions and client information for the types of work assignments you are interested in working with Bluecrew: *

Identify the physical and/or mental impairment(s) for which you are requesting accommodation(s) or work restriction and the expected duration of the impairment(s). Also, please include the date of diagnosis. Note: In order to apply for a reasonable accommodation, the individual will be required to provide documentation of his/her functional limitations to support the request. For example: written documentation from a doctor, psychologist, rehabilitation counselor, occupational or physical therapist, independent living specialist, or other professional with knowledge of the employee’s functional limitations is required. *

Explain how the impairment(s) that you listed affect your ability to perform the essential functions of the desired job position. If you are a new employee, state the anticipated difficulties you foresee in completing the described job duties. Be as specific as possible regarding the job duties you would have difficulty performing. Note: Essential functions are duties that are basic or fundamental to a position and cannot be eliminated or transferred to another job position. *

What specific job-related accommodation or work restriction(s) are you requesting, and how will this assist you? *

Please share what types of accommodation, equipment, or other assistance you have successfully used in similar jobs?

Provide any additional information that might be useful in processing your accommodation request, such as if you have a service animal that you will bring to the worksite with you, what work or tasks has this animal been trained to perform? *

If you have a service animal or emotional support animal, please affirm you have read and agreed to all statements below by checking the boxes:

I am able to control my animal at all times in any environment.

My service or support animal is trained and will not distract other employees' while working.

If my animal is out of control or is a safety concern, the animal must leave the premises.

My animal is housebroken, and will relieve itself in the assigned outdoor area.

If the job requires driving a vehicle, my animal must be in a safe location.i.e. carrier or on floorboard).

If client's safety and other workplace rules are not followed, my animal may be prohibited from worksite.

Bluecrew reserves the right to request medical documentation to verify the existence of a disability; and, to appropriately assess your condition, functional limitations, and/or request for reasonable accommodation. Failure to provide such requested medical documentation to Bluecrew may hinder our consideration or result in rejection of the request. An employer is not required to make a reasonable accommodation if it would impose an undue hardship on the operation of the business (Bluecrew's or our clients). Whether a reasonable accommodation will impose an undue hardship is determined on a case-by-case basis. Please acknowledge that you read and understood this policy by typing "Agreed" below. If you do not understand or do not agree to provide the requested information, we cannot continue our consideration of your request without your agreement, so you can stop completing this form. *

What is the basis for your request for a reasonable accommodation to the vaccination requirement for a sincerely held religious belief? (Select all that apply) *

I believe vaccine mandates restrict my personal freedoms

I believe vaccines are bad for the environment

I believe that diseases should only be cured through prayer

I believe vaccines interfere with my relationship with God

The potential use of fetal tissue in the development of the vaccine is against my beliefs

My church/religion/spiritual leader advises that taking the vaccine is a sin

The vaccines have not been tested enough

Required

Are any of the following true? (Select all that apply)

I have been vaccinated against diseases in the past (for example, measles vaccine or flu shot)

I take over the counter medication, for example Tylenol, to treat illness or pain

I would receive a vaccine if it was fully tested by the FDA for 3 years

Is there anything else you'd like us to know about your request for a reasonable accommodation on the basis of a sincerely held religious belief?

Date Request Submitted *

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