CONFIDENTIAL
Employee Disability Accommodations Request Form
An employee who wishes to request a reasonable accommodation should complete this form with a qualified health care
professional. The form and supporting documentation must be submitted to Human Resources. The form will be
maintained separately from the employee’s personnel file. For service animal requests and additional information, please
refer to the Accommodations for Employees with Disabilities policy
.
Documentation should be as descriptive as possible. At minimum, it should include the following information:
1. A diagnostic statement identifying the disability, date of the most current diagnostic evaluation, and the date of the
original diagnosis.
2. A description of the diagnostic tests, methods, and/or criteria used.
3. A description of the current functional impact of the disability which includes specific test results and the
examiner’s narrative interpretation.
4. Treatment, medications, and/or assistive devices/services currently prescribed or in use.
5. A description of the expected progression or stability of the impact of the disability over time, particularly during
the employee’s expected time at Durham Tech.
6. Recommended accommodations/services (i.e., flexibility in hours/duties, specialized furniture/equipment) for the
work environment.
7. The name, credentials, and license number of the diagnosing professional.
All documentation must be typed, signed by a qualified health care professional, submitted on the health care
professional’s letterhead, and include the date the documentation was completed. If the employee provides incomplete or
inadequate documentation to substantiate his or her disability and/or the need for the requested reasonable
accommodation, the College may, at its discretion, require the employee to provide additional information. The employee
is responsible for all associated expenses; the College is not financially responsible for any costs related to
documentation required to support the need for an accommodation.
EMPLOYEE INFORMATION
First Name: ____________________________________ Last Name: _________________________________________
ID Number: ____________________________________
Title: _________________________________________
Department: ___________________________________ Division: ___________________________________________
HEALTH CARE PROFESSIONAL INFORMATION
First Name: ____________________________________ Last Name: _________________________________________
Practice/Hospital Name: _________________________
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