COVID-19 Screening Remote Employee Exemption Request

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Use this form to request an exemption from participation in the COVID-19 screening program if you are an employee who is working entirely remotely and will not have a physical presence on campus during the Spring 2021 semester. Once you submit this form, your request will be reviewed by a member of our HR team, and you will receive a response as soon as possible.

Email *

Your name (first and last, please): *

What is the best phone number for us to reach you? *

Bengal ID: (This is listed under "ISU ID" in Bengal Web for faculty/staff and students. If you do not have a Bengal ID, enter "NA") *

What is your affiliation with ISU? (select all that apply) *

Faculty (including adjunct, instructor)

Staff (including temporary staff)

Undergraduate Student

Grad Student/TA

Student Employee

Health Sciences Resident (Medical, Dental, Pharmacy, etc.)

ISU Contract Employee/Affiliate

Other:

Required

Department: *

Supervisor name: *

Do you currently have an approved telework agreement on file with HR? *

Yes - and it has no end date

Yes - but it had an end date of December 2020

I'm not sure

Other:

Please select which of the following best describes your spring semester work situation: *

I am working entirely remotely, and will not physically interact with anyone else from the campus community or use campus services (Rec Center, Library, etc.)

I am working remotely, but will occasionally physically interact with my colleagues for meetings or to pick something up, etc.

I was an adjunct faculty member in the fall, but am not returning for the spring 2021 semester

Other:

If granted an exemption, do you agree to comply with the guidelines of the mandatory COVID-19 screening program and continue working entirely remotely throughout the spring 2021 semester? *

Yes, I agree

No, I don't agree

Other:

If granted an exemption, do you agree that if your remote work situation changes at any point during the semester, you will contact HR immediately to be enrolled in the COVID-19 mandatory screening program? *

Yes, I agree

No, I don't agree

Other:

A copy of your responses will be emailed to the address you provided.

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