Reasonable Accommodation Log

Employees or applicants requiring an accommodation may request one by filling out this Reasonable Accommodation Request form or otherwise informing the supervisor, HRBP, hiring or talent manager of the need for accommodation.

Every accommodation request will be reviewed and the decision will be made on a case by case basis, considering each employee’s individual limitations and accommodation needs.

While it is not required to disclose medical information to a supervisor, hiring manager or co-workers, medical documentation (or additional medical documentation) can be requested by Equal Employment Opportunity Office in order to process an accommodation request. It is the requestor's responsibility to obtain information from the healthcare provider and submit to the HRBP or EEO Office in a timely manner.

Select one option that applies*

Applicant Existing WSP USA Employee Acquisition Company Employee

Employee ID *

Company Name*

WSP USA Earth Con Golder & Associates KW tk1sc Other

Acquisition Company Name *

Earth Con Golder & Associates KW tk1sc Other

Req ID (4 digit code underneath job title)

Name*

First Name

Last Name

Email*

Location

Manager Name

First Name

Last Name

Phone

________________________________________________________________________________________________________

What type of accommodation are you requesting?*

Accommodation (work related)

What type of accommodation are you requesting? - Copy

Religious Exemption (COVID Related) Medical Exemption (COVID Related) Accommodation (work related)

2. What, if any, job function are you having difficulty performing?*

Have you had any accommodations in the past for this same limitation? *

Yes No

If yes, what were they and how effective were they?

Please provide any additional information that might be useful in processing your accommodation request*

Please upload supporting medical documentation (ie: doctor's note) and provide any relevant information that might be useful in processing your request

A. Please describe the specific religious belief, observance, or practice to which you adhere

B. Is your belief based upon religious belief or is it based upon a personal, ethical, philosophical, medical, or scientific objection to the vaccine?

C. If religious, when did you embrace this religious belief, observance, or practice? Please describe.

D. Describe how that belief forms a basis for objecting to the vaccination. Do you have any documentation to support your belief?

E. Would complying with the COVID-19 vaccination requirement substantially burden your religious exercise? If so, please explain how.

F. How long have you held the religious belief underlying your objection?

G. Please describe whether, as an adult, you have received any vaccines against any other diseases(such as a flu vaccine or a tetanus vaccine) and, if so, what vaccine you most recently received and when, to the best of your recollection.

H. If there are any other medicines or products that you do not use because of the religious belief underlying your objection, please identify them.

Upload a file (optional)

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Signature*

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Use your mouse or finger to draw your signature above

The request will be evaluated and a response to any medical information received will be done on a timely manner. Additional Information may be required in which case you will be contacted.

Responsibility for implementing the policy has been assigned to Martha Alongi - 2202 N. West Shore Blvd. Tampa FL 33613 (Martha.Alongi@wsp.com). If you do not know who to contact or if further information about the plan is required, you can contact her or her designee.