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COVID-19 Vaccine Medical/Disability Accommodation Request Forms

Please read carefully below to select the correct form and submission process. 

Centers for Medicare & Medicaid Services (CMS) clinical/practicum experiences

Download the form for CMS clinical/practicum experiences.

Who should use this form: This form is for Penn State graduate, medical, and undergraduate students who must complete clinical/practicum experiences in agencies and sites that bill patients under Medicare and Medicaid. 

How to submit this form: Students should submit the form to University Health Services by logging into myUHS and uploading an image of the completed COVID-19 Vaccination Requirement Medical/Disability Accommodation Request.

Graduate assistantships

Download the form for students supported on graduate assistantships.

Who should use this form: Penn State students supported on graduate assistantships. 

How to submit: Students should submit the form to University Health Services by logging into myUHS and uploading an image of the completed COVID-19 Vaccination Requirement Medical/Disability Accommodation Request.