Reasonable Accommodation Request Form For Employees
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1
2Reasonable Accommodation
263 Farmington Avenue
Farmington, CT 06030-5310
Request Form for Employees
Telephone 860-679-3563
Facsimile 860-679-3805
All information regarding an individual's medical condition and the reasonable accommodation request is confidential and only disclosed to persons on a need
to know basis. Any and all documents related to this request are kept confidential and will be maintained and used in accordance with applicable state and
federal law.
Faculty
Employee/Staff
Other (specify) _______________________
Instructions: Individuals who are employed at
the UConn Health and are requesting a
Name: ________________________________________________________________________
reasonable accommodation(s) under the
First
Middle
Last
Americans with Disabilities Act of1990 (ADA),
Section 504 of the Rehabilitation Act, relevant
Job Title: ______________________________________________________________________
state law, and accompanying state and federal
regulations, are encouraged to complete this
Department: ___________________________________________________________________
form in its entirety.
Work Address: __________________________________________________________________
In order to explore possible coverage and
City
State
ZIP Code
reasonable accommodations, information is
required regarding your medical condition,
Work Telephone Number: _________________________________________________________
essential job functions, applicable functional
limitations and your requested
Work Email: ____________________________________________________________________
accommodation(s). It is often necessary for
staff of the Office of Institutional Equity to
Home Address: __________________________________________________________________
discuss your medical condition and the
City
State
ZIP Code
documentation you submit to our office with
providers such as licensed physicians,
Home Telephone Number: _________________________________________________________
psychologists, or other qualified professionals.
If you need help in completing this form,
Home Email: ____________________________________________________________________
someone else may complete it on your behalf,
or you may contact the UConn Health's Office
Preferred method of contact:
Home Phone
Home Email
of Institutional Equity at (860)679-3563.
Work Phone
Work Email
How long have you worked/studied in current position? _________________________________
Upon completion, please forward this
form,
along with the
Medical Release
Form, to
How long have you worked/studied at UConn? ________________________________________
UConn Health's Office of Institutional
Equity. Make sure you sign both forms.
Supervisor's Name: _______________________________________________________________
First
Middle
Last
FOR UConn Health:
Job Title: _______________________________________________________________________
Office of Institutional Equity
UConn Health
Department: ____________________________________________________________________
263 Farmington Avenue
Farmington, CT 06030-5310
Work Telephone Number: _________________________________________________________
Telephone - (860) 679-3563
Facsimile – (860) 679-
Work Email: _____________________________________________________________________
Email –
equity.uconn.edu
Medical Information
Please identify the medical condition(s) for which you are requesting an accommodation.
Please provide the name and contact information for the health care professional who diagnosed
the medical condition(s) listed above. Please include the date of diagnosis.
Revised 07/2016
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Parent category: Business