reasonable accommodation form
If you are unable to complete a health screening or meet 3 out of 4 of your target numbers due to a health condition, you have the option to complete the Reasonable Accommodation Form to receive credit.
- Print a copy of the Reasonable Accommodation Form.
- You must have this form notarized. Take the form to a notary, sign and date the form with the notary.
- Make a copy of the form for your records. Then, return the original notarized copy to the Plan Office at the address listed on the form. You may send the form via mail or bring the form to the office during business hours.
For more information regarding the health screening and LiveWell Program, please review the EEOC Wellness Notice.
Return to the main Health Screenings page.