Employee Request for Accommodation Form
Applicant or Employee Name: Date:
Position or Title:
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
Accommodation approved or denied:
Summary of outcome (attach any supporting
documents) Request for Appeal: __Yes __No
Summary of outcome (attach any supporting documents)
Signature of ADA Coordinator or designee:
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.
click to sign
click to edit