Student

Face Covering
Accommodation Request Form

This form must be completed for any student that is unable to wear a
traditional face mask that covers the nose and mouth. A parent/guardian that
is requesting that their student wear another facial covering alternative will
need to complete this form, in order to be granted an appropriate
accommodation.
The importance of in-person learning is well-documented. According to the American
Association of Pediatrics (AAP), “schools are fundamental to child development and well-being
and provide our children and adolescents with academic instruction, social and emotional skills,
safety, reliable nutrition, physical/speech and mental health therapy, and opportunities for
physical activity, among other benefits.”

Public health authorities, school nurses, school staff, and parents acknowledge the reality that
any protocols related to COVID-19 are intended to mitigate, not eliminate, the risk of
transmission of this disease. The National Association of School Nurses (NASN) and the AAP
recognize that “no single action or set of actions will completely eliminate the risk of
SARS-CoV-2 transmission in schools, but implementation of several coordinated interventions
can greatly reduce that risk.” For example, where physical distance cannot be maintained,
students (over the age of 2 years) and staff can wear face coverings when feasible.

Every child and adolescent with a disability is entitled to a free and appropriate public education
based on their individualized education program (IEP) or accommodations allowed by Section
504 of the Rehabilitation Act. It may not be feasible, depending on the needs of the individual
child and adolescent, to adhere to the requirement to wear a face covering at school. Attempts
to meet face covering guidelines should meet the needs of the individual child and may require
case-by-case creative solutions.
 Overview of Process
1. Parent or guardian notifies school administrator, special services case
manager, or school nurse of the need for an accommodation to the face
covering requirement.
2. Provide parent/guardian with the four-page “Request for Face Covering
Accommodation” packet.
3. Pages 1-2 to be completed and signed by parent or guardian.
4. Pages 3-4 to be completed and signed by a licensed healthcare provider,
including the provider’s contact information.
5. Forms returned to the school nurse, who will consult with the student's 504
coordinator or special services case manager to review the request.
6. If approved, a plan for maintaining the health and safety of the student and
other individuals in the school will be determined.
7. District may verify all information provided by the student’s
parent/guardian and/or the student’s healthcare provider through an
independent review by a licensed medical provider of the District’s choice.
This form, along with the physician verification form, must be completed in its entirety by
parents/guardians who are requesting an accommodation to the District’s Face Covering
Protocol. The completed forms should be turned into the school nurse who will consult with
504 coordinator or special services case manager to review the request and, if approved,
determine a plan for maintaining the health and safety of the student and all other individuals
in the school.

The District may verify all information provided by the student’s parent/guardian and/or the
student’s physician through an independent review by a licensed medical provider of the
District’s choice.

Student Name Student

Name
Name of Parent/ Phone
Guardian Number
Parent email address
My student has a ❏ IEP ❏ Health Plan
current ❏ 504 Plan ❏ New medical condition
Please identify the reason for the request for the accommodation

Please identify the accommodation you are requesting

I authorize the District and the Physician who completes this form to mutually exchange
information, including telephone or virtual conversations, concerning my student’s medical or
behavioral condition and the impact of the condition on my student’s compliance with the
District’s face covering protocol. This authorization is valid for the entire 2020-2021 school year
unless otherwise revoked in writing. I understand that I may revoke this authorization at any
time by submitting written notice of the withdrawal of my consent. I understand that failing to
authorize disclosure of information may impact the District’s ability to grant my request for
reasonable accommodations. I recognize that health records, once received by the school
district, may not be protected by the HIPAA Privacy Rule, but will become education records
protected by the Family Educational Rights and Privacy Act. I also understand that if I refuse to
sign, such refusal will not interfere with my child’s ability to obtain a free education.

Parent/Guardian Name: _________________________ Date:_________

Parent/Guardian Signature: ____________________________________

 Medical Verification Form

Verification of Medical Exemption for Face Covering

Must be completed practitioner (MD/DO/APRN) licensed to practice medicine in Texas
Student Name Date of Birth
Identify the condition that
prevents the individual from
wearing the required face
covering.

Explain, with specificity, the

nature of the individual’s
condition and why it is
medically contraindicated for
the individual to comply with
the district’s face covering
protocol attached.
Please indicate the specific
detrimental effect of the face
covering requirement.

Are there any accommodations

that would address the
individual’s needs and enable
compliance with the face
covering protocol?

If there are no accommodations

that would allow compliance
with the face covering protocol,
please
identify precautions that can be
taken to offer the same or
similar protection to others?
 If face coverings cannot be required under any circumstances, please complete
the following questions:
Is the individual able to be around others who wear face ❏ YES
coverings or other protective equipment? ❏ NO
If no, please explain:

Is the individual able to be around others who are also unable ❏ YES
to wear face coverings if social distancing is maintained? ❏ NO
If no, please explain:

Any additional
recommendations or
information we need to
protect the health and safety
of the student or others?

I hereby certify that this student has a medical condition that requires accommodations to or
exemption from to the face covering protocol as stated above.
Provider Printed Name

Provider Signature

Date

Provider Contact Information