Employee Accommodation Request

Employee Information

Thank you for taking the time to complete the Employee Accommodation Request form. This information will assist us in navigating the interactive process with you. Your responses are confidential and will be maintained under ADA confidentiality guidelines. If you have any questions throughout this process, please don’t hesitate to contact our office.

First Name

Last Name

Chosen Name

Pronouns

ID Number

Employee # or PID (Student)

Email

Please use your corporate email if existing employee

Preferred Phone Number

Work Address

Campus

Position Information

Position Information Other

Department

Position Title

Supervisor's Name and Title

Supervisor's Phone

Supervisor's Email

Work Status

Work Status Category

Disability Information

Please describe how your disability impacts you:

What limitation is interfering with your ability to perform your job or access an employment benefit?

Indicate disability type:

Select all that apply.

What, if any, job function are you having difficulty performing?

What, if any, employment benefit are you having difficulty accessing?

What specific accommodation are you requesting?

Please provide any additional information that might be helpful in reviewing your accommodation request:

Upload supporting document(s)

Please upload any supporting documentation (i.e. physicians forms) that may be helpful in processing this request.