Confirmation Of Request For Reasonable Accommodation (Page 4 of 4) in pdf

Confirmation Of Request For Reasonable Accommodation Page 4

REASONABLE ACCOMMODATION INFORMATION REPORTING FORM

Name of individual requesting reasonable

accommodation:________________________________________________________

Office of Requesting Individual:___________________________________________

Reasonable accommodation: (check one)

___________Approved

___________ Denied (if denied, attach copy of the written denial –See section 2, pages

7/8 of the Reasonable Accommodation Procedures)

2.- Date reasonable accommodation requested:__________________________________

Name and title of person receiving the request:___________________________________

Date reasonable accommodation request referred to decision maker (i.e. supervisor,

Office/Division Director, DPM, Personnel Specialist)

Name of decision maker:__________________________________________________

4. Date reasonable accommodation approved or denied:___________________________

5. Date reasonable accommodation provided ( if different from date approved):

6. If time frames outlined in the Reasonable Accommodation Procedures were not met,

please explain why: (attach extra sheet if needed)

Confirmation Of Request For Reasonable Accommodation Page 4