ADA: Request for Reasonable Accommodation Form
Name: ____________________________________________ Date: ________________________________________
Work phone: ______________________________________ Home Phone: _________________________________
Email: ____________________________________________
Position: __________________________________________ Department: __________________________________
Supervisor/Department Head: _______________________________________________________________________
NATURE OF THE QUALIFYING DISABILITY: (Please describe the nature, extent, and duration of your disability.)
REQUESTED/SUGGESTED ACCOMMODATION: (Please describe the accommodations you believe are needed to
enable you to perform the essential functions of this job.)
PHYSICIAN CONTACT INFORMATION (Employees only) (Please provide name, address, telephone and fax
numbers. The physician may receive a letter/fax from us requesting information on your impairment/disability and
recommendations for accommodations.)
Name: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________
Telephone: _______________________________________________________________________________________
Fax Numbers: ____________________________________________________________________________________
I authorize the release of necessary confidential medical information regarding my disability to relevant hiring
managers as deemed necessary by Human Resources. I also attest to the fact that a copy of the position description
has been given to me for review and reference.
Signature: _______________________________________ Date: _______________________________________
[To signatory: In non-physician review cases, decisions regarding accommodations will be made within 10 days of the receipt
of this form by Human Resources. Due to delays that may be caused in communications with physicians, no specific decision
date can be provided for physician review cases.]
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