ADA Reasonable Accommodation Reporting Form
This form is to be filled out by a college representative for every reasonable accommodation
processed for staff or faculty. Please do not use this form to request an accommodation.
Attach separate sheets if necessary in order to complete each question. Upon completion, please mail to
Human Resources, BCB 382.
Please note: If this form is being filled out due to a request for a reasonable accommodation from an
applicant, please note “Applicant” If the applicant does become an ASU employee, please inform Human
Resources so that the data on this form is tracked into the system.
Department of person making request: ____________________________________________________
Name of individual requesting the reasonable accommodation (s):_______________________________
Date reasonable accommodation requested: __________________
Job held or desired by individual requesting reasonable accommodation: _________________________
Reasonable accommodation needed for:
____1. Application process
____2. Performing job functions or accessing the work environment
____3. Accessing a benefit or privilege of employment (e.g. attending a training or social event)
____4. Adjustment to existing leave
____5. Other: _________________________________________________________________________
Details of the request:
Did documentation come with the request? _____ Yes ______No
Is more documentation necessary? _____ Yes ______No
Reasonable accommodation: ____Approved ____ Modified _____Denied ____Undue Hardship
Type of accommodation provided: ________________________________________________________
Date reasonable accommodation approved or denied: _________________________________________
Authorized person approving or denying the accommodation: ___________________________________
Date reasonable accommodation provided (if different from date approved):________________________
Costs associated with the reasonable accommodation: ________________________________________
Names of sources of assistance consulted in trying to process these reasonable accommodations (HR,
Legal or External):___________________________________________________________________
Additional Comments:
__________________________________________________ ________________________
Submitted by (Department Manager name and title) Phone