APPENDIX A
ACCOMMODATION REQUEST FORM
RETURN THIS COMPLETED FORM TO HUMAN RESOURCES
1340 State Route 9, Lake George , NY 12845 – Fax 518-761-6509
I, ___________________________, understand that I am giving permission to the Warren County
Human Resources and/or Self-Insurance Departments to contact the following individual(s) for purposes
of requesting documentation/information regarding my disability including the diagnosis and limitations
associated with that diagnosis.
I understand that this permission will remain in effect from the day I sign this document until I revoke
permission in writing or am no longer affiliated with Warren County.
Provider Name:
Address:
Phone: Fax:
Provider Name:
Address:
Phone: Fax:
Provider Name:
Address:
Phone: Fax:
I understand that communication with the above names individual(s) will not include personal disclosures
that so not pertain to my disability(ies). I understand that all medical information related to my request
for accommodation is confidential and will be maintained in a secured location within the Human
Resources Department separate and apart from my personnel file. I further understand that I will be
required to provide appropriate documentation of my disability, including the impact of functional
limitations on my ability to perform the essential functions of my job.
________________________________________________ ________________
Signature Date
