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Form to Initiate Request for a Reasonable Accommodation

Please provide the following information:

Today's Date: (MM/DD/YYYY)

Your Full Name:

Your Division:

Please provide the following:

Your Department:

Your Title:

Your Email Address:

Best Phone Number to Contact You:

Start Date of Your Request: (MM/DD/YYYY)

End Date of Your Request: (MM/DD/YYYY)

Your Supervisor / Department Head:

What accommodation(s) are you requesting? Possible accommodations might include, but are not limited to, work space modification, equipment, flexible work options, etc. (Please enter each accommodation request on a separate line.)

Request #1

Request #2

Request #3

Request #4

In order to evaluate your request for accommodation, Human Resources will request that you have your medical provider provide us with a written explanation of the nature of the medical condition, any functional limitations, and any accommodation needed. If any additional follow up is needed with the provider, we will ask you to arrange for that to occur. Please be assured that any medical information provided to Human Resources will remain confidential and will not be shared with your supervisor/division head.

Human Resources will also discuss your request with your supervisor/division head. After consulting with them, we will be in touch with you regarding next steps.

Thank You!

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