Request For Reasonable Accommodation
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1CONFIDENTIAL
Date of Request ________________________
Johns Hopkins Health System Corporation
The Johns Hopkins Hospital
Request for Reasonable Accommodation
Person Requesting Accommodation
Please circle status:
Applicant
New Hire
Employee
Intrastaff
Temporary/Agency
Name __________________________________________
Title _______________________________________
Department _____________________________________
Telephone # _________________________________
E-Mail _________________________________________
Supervisor __________________________________
Person Completing Form (If different from above)
Name _________________________________________
Telephone # _________________________________
Department ____________________________________
Title _______________________________________
Relationship to Person Requesting Accommodation ______________________________________________________
Request for Accommodation
Description of Hiring Process, Job Functions, or Benefits/Privileges Affected by the Disability
Description of Accommodation Requested
•
Email (preferred method) or fax this Request Form to the attention of Kate Weeks (Fax No. 410-735-7569)
•
Schedule an appointment with Occupational Health Services (Phone: 410-955-6211)
•
Forward medical documentation requested by Occupational Health Services to support your request
Signature of Person Requesting Accommodation
Date
Signature of Person Completing Form
Date
Employer’s Use Only
Dept. Submitted To: ____________________
Date Received: ___________
Initials of Recipient _______
Date Received in HR: ___________________
Initials of Recipient in HR: ________
Attachment A_Confirmation of Request for Reasonable Accommodation - Revised(ADA 09202013)
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