Fillable Disability Accommodation Request Form printable pdf download

Disability Accommodation Request Form

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State of Wisconsin

Office of State Employment Relations

Division of Affirmative Action

101 East Wilson Street, 4th Floor

Madison, WI 53703

DISABILITY ACCOMMODATION REQUEST FORM

Agency or UW System Unit:

Division (or other secondary unit):

SECTION I: Employee

Name of Employee:

Job Title:

Signature:

Date of Request:

My disability is (e.g., visual impairment, arthritis, etc.):

My disability impairs my ability to perform assigned job duties in the following way (attach additional pages if

necessary):

The reasonable accommodation I am requesting is (attach additional pages if necessary):

SECTION II: Employer

Accommodation Request is: __ Approved

__ Denied

__ Modified

If modified, describe modification and give rationale. If denied, give rationale. (Attach additional pages if necessary.)

Name of person making decision:

Cost of Accommodation: __Estimate

__Actual

Signature:

Date:

DISTRIBUTION AFTER COMPLETION:

Original - Employee

Copy - Agency Confidential File

Copy - OSER/DAA (with employee identification blinded)

OSER-DAA-10 (rev. 3/94)

Disability Accommodation Request Form

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