Temporary Accommodation or Workplace Adjustment for UCI Academic Appointees, Staff, Student Employees

Faculty or staff whose age or underlying medical condition falls within one of the CDC High Risk Categories or who have other special circumstances may seek a workplace adjustment or reasonable accommodation by utilizing this form.

You may be requested to submit medical documentation in support of your COVID-19 Accommodation request due to an underlying medical condition. Email medical documents to UCI’s Employee Experience Center and reference this request form.

All fields are required.











Work PhonePersonal Phone

Dean, Chair, Vice Chancellor or Supervisor






Information about Your Reasonable Accommodation or Workplace Adjustment Request
The U.S. Centers for Disease Control and Prevention (CDC) advises that although everyone is at risk for getting COVID-19 if exposed, some people are more likely than others to become severely ill. People at increased risk for severe illness include older adults and people with underlying medical conditions. Please check the CDC website for the latest information on individuals who are at increased risk of severe illness from COVID-19.





Are you requesting a workplace adjustment and/or leave of absence for any of the following circumstances which are unrelated to being at increased risk?

  • You are a caregiver for an individual with a disability;
  • There is someone in your household who has a medical condition or disability;
  • Childcare concerns

If yes, because your request is not based on your age, medical condition, or being in the CDC’s increased risk category; you do not qualify for the disability accommodation or workplace adjustment process for employees in that category. You may request workplace adjustments by contacting your department’s human resources or academic personnel representative for assistance. Also, you may continue to submit this form, and it will be routed to the appropriate office.



UCI strives to be creative and flexible in arriving at a reasonable accommodation or workplace adjustment due to COVID-19. Disability Management Consultants with Human Resources (HR) provide guidance and assistance to identify reasonable accommodations that could reduce COVID-19 related risks to employees at increased risk. Reasonable accommodations are determined, identified and implemented in a collaborative process among the employee, supervisor/department and HR.

In general, it is the employee’s responsibility to inform their supervisor that they need a COVID-19 related accommodation. A supervisor is not required to provide reasonable accommodations if they are not aware of the employee’s need for the accommodation.

Contents of this request are confidential and will only be shared as needed with the appropriate personnel to consider the request for reasonable accommodation.

This is to acknowledge that I am requesting a reasonable accommodation and or workplace adjustment based on my age category, and/or I am requesting a reasonable accommodation based on an underlying medical condition. I agree to fully cooperate with HR in responding to my request, including providing medical documentation, if needed. I understand that I may not be provided with my specific request and that the University will consider my request in addition to those identified by the University.

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