Student Requesting Reasonable Accommodations To The COVID-19 Vaccine Policy

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Reasonable Accommodation(Required):

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Date of Request(Required):

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Location of Classes Requesting(Required):

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Student Information

The student must provide a full name (first and last), Bristol ID (900 Number), phone number, and Bristol email address. Submissions without this information will not be reviewed.

Student Name

Student ID Number

DOB (YYYY-MM-DD)

Student Phone number

Student Email address

Please Answer the Following Questions

Describe why you are unable to be fully vaccinated against COVID-19 and/or unable to submit verification of full vaccination status in compliance with the Student Vaccination Policy.(Required) This field is required.

Describe the reasonable accommodation you are requesting and all other alternate reasonable accommodations considered (i.e.; wear a mask, test if required). Please also list any other alternate reasonable accommodations that may address your needs.(Required) This field is required.

Special Circumstance: If your request is based on a special circumstance that is not related to disability or religion but which you believe would qualify you for a reasonable accommodation, explain in detail the nature of, and rationale for, your request.(Required) This field is required.

By checking the box below; I acknowledge that while a request for reasonable accommodation is pending I should not expect to be able to attend classes or be permitted on campus following the effective date of the student vaccination policy.(Required)

I acknowledge

You must make at least one selection.

By checking the box below; I acknowledge that the individualized interactive process is estimated to take a minimum of ten (10) business days after receipt of satisfactory documentation supporting my eligibility for reasonable accommodation and clarification and/or additional documentation may be requested at any point in the interactive process. I understand the interactive process cannot begin until I have submitted truthful, complete and accurate information and all supporting documentation requested.(Required)

I acknowledge

You must make at least one selection.

By checking the box below; I acknowledge if the information I submit is deemed to be fraudulent or untruthful I may be subject to interim measures and/or discipline consistent with the College’s Student Code of Conduct.(Required)

I acknowledge

You must make at least one selection.

By typing your name below, I certify that the information I have provided on this form, including any attached documentation, is truthful, complete and accurate.(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.