Fillable Employee Request for Accommodation Form -Confidential- (City of Stephenville)

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Employee Request for Accommodation Form -Confidential- (City of Stephenville)

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The Employee Request for Accommodation Form -Confidential- (City of Stephenville) form is 1 page long and contains:

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  • 2 check-boxes
  • 17 other fields

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Employee Request for Accommodation Form
-Confidential-
Applicant or Employee Name: Date:
Position or Title:
Department/Supervisor:
Applicant or Employee – Please complete this section, and return the completed form to the Human Resources
department. Request is confidential and will only be shared with those who have a right to know.
Human Resources Use Only
Date(s)reviewed:
Date Reviewed:
Date Received:
Accommodation approved or denied:
Summary of outcome (attach any supporting
documents) Request for Appeal: __Yes __No
Date Received:
Summary of outcome (attach any supporting documents)
Signature of ADA Coordinator or designee:
Date
APPENDIX E
FORM 24
Identify your condition(s) and indicate how you believe each condition affects your ability to perform the essential
duties of the position:
State the requested accommodation(s) and any alternatives.
Page 231 of 254
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Employee Request for Accommodation Form -Confidential- (City of Stephenville)

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Completed 3 March 2021

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