Universal Face Covering Exemption or Accommodation Request
Please complete a separate survey for each student for whom you are requesting an exemption or accommodation.
Email *
Name of person completing the survey *
Student name *
Building *
Required
Does the student have an Individualized Education Program (IEP) or a 504 Plan? *
Required
If the student does not have an IEP or 504 Plan, can you provide documentation of a medical or mental health condition or a disability? *
Required
Please describe the medical or mental health condition or disability for which the exemption or accommodation is being requested. *
Please describe the exemption or accommodation you are requesting (full exemption, mask breaks, support to gradually increase mask time, use of a shield, etc.) *
If the child for whom you are requesting an exemption or accommodation wore a mask during the previous mandate with no accommodation other than mask breaks provided to all students, please describe how the student's condition has changed. *
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