Skip to content
Skip to main menu
Skip to secondary menu
Reasonable Accommodation Form
*
indicates a required field
Employee Information
Please enter your information
First Name
Required
*
Last Name
Required
*
Middle Name
Employee ID
Required
*
Email
Required
*
Please use your university issued email address
Phone Number
Required
*
Job Classification/Title
Supervisor
Department
Division
Specific Accommodation Information
My diagnosed disability falls into the following category
Required
*
What specific accommodation are you requesting?
Required
*
Accessibility Accommodation
Accommodation Type
Other Accommodation
Is your accommodation request time sensitive?
Is your accommodation request time sensitive?
Yes
Is your accommodation request time sensitive?
No
Is this for a limited time?
Is this for a limited time?
Yes
Is this for a limited time?
No
What job function(s) are you having difficulty performing, if any, based on your position description and/or daily job responsibilities?
Required
*
What limitation (major life function) is interfering with your ability to perform your job?
+
Select visible
-
Clear visible
clear filtering
Bending
Breathing
Caring for Self
Concentrating
Eating
Reaching
Sitting
Speaking
Walking
Working
Other
Thinking
Standing
Sleeping
Seeing
Reading
Performing Manual Tasks
Lifting
Learning
Interacting with Others
Hearing
21 of 21 visible
0
of
21
selected
show selected
show all
Other limitation (major life function)
Have you had any accommodations in the past?
Have you had any accommodations in the past?
Yes
Have you had any accommodations in the past?
No
If yes, what were they? How effective were they? Why did the accommodations end? Was it the same limitation?
Has your limitation/disability been diagnosed by a Physician?
Has your limitation/disability been diagnosed by a Physician?
Yes
Has your limitation/disability been diagnosed by a Physician?
No
If yes, please provide contact information for your Physician (name, address, telephone number). You may attach official documentation from your Physician concerning your limitation.
Please provide any additional information that might be useful in processing your accommodation request.
Upload supporting document(s)
Document Information
Document Title
File
Required
*
Maximum file size: 10240kb
Description