Accommodation Request Form – Human Resources

To Employee: Please complete this form to the best of your ability. It will be sent to the Human Resources Department upon submission. This form is to initiate the process of investigating and evaluating your request for accommodation. You will have the opportunity to submit additional information about your accommodation request.

Requestor's name(Required)

First Last

Job title(Required)

Please explain why you believe that you require an accommodation(Required)

Please describe the condition or impairment that gives rise to your request for an accommodation, including (1) how it impacts your daily life activities, (2) low long you expect that it will last and (3) whether you are currently receiving medical treatment for it.(Required)

How does your condition or impairment impact your ability to perform your job?(Required)

Please identify any specific accommodations that you would like us to consider.(Required)

Supervisor's Name(Required)

First Last

Additional Comments

Requestor's Signature(Required)

Please contact Human Resources if you prefer to use a paper form instead of the online form.