Reasonable Accommodation Request Form For Employees Page 2
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2Job and Accommodation Information
Please explain how your medical condition(s) listed in Section B affect(s) your ability to perform the essential functions of your position. If you
are a new employee, state the anticipated difficulties you foresee in completing your job duties. Be as specific regarding the job duties you are
having difficulty performing or believe you will have difficulty performing.
Please provide your recommendations for a reasonable accommodation(s) and any information you may have about any associated costs
(attach supporting documentation).
Please describe any accommodations or assistive technologies you currently use.
Please identify any University employee with whom you have discussed this request for a reasonable accommodation (i.e. , co-worker,
supervisor, HR, etc.) Please include dates
Please add any comments you feel may be helpful in consideration of your request.
Acknowledgement
I understand that it will be my responsibility to complete a Medical Release Form and provide it to the ADA Accommodations Case Manager for
my request to be evaluated. I further understand that the ADA Accommodations Case Manager will evaluate and respond to me based upon
the information that I provide.
_______________________________
_________________________
Signature
Date
Please check here if additional information is attached to this request.
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