Click here to download the Employee Request for Accommodation Form
Employee Name: ____________________________________
Current Position: ____________________________________
Supervisor Name: ____________________________________
Employee: Upon completion please submit this document to your direct supervisor or the Human Resources Office.
Identify your condition(s) and indicate how you believe each condition affects your ability to perform the essential functions of your job:
_______________________________________________________________________________
State the accommodations you are requesting and any alternate suggestions:
_______________________________________________________________________________
_______________________________________________________________________________
Employee Signature: ______________________________ Date: __________________________________
Human Resources: _______________________________ Date Received: ____________________________
Reviewed: 9/14; 8/17; 6/20; 4/23
Related Policy: 403.24