USG Reasonable Accommodations Request Form
USG Accommodations Request Form | 1
The University System of Georgia (USG) provides reasonable accommodations for employees with
ADA defined disabilities OR who may be covered by public health emergency guidance when
necessary. A reasonable accommodation is an accommodation that enables the employee to
perform the essential functions of their position, is medically necessary, and does not create an
undue hardship to the institution. Employees who are requesting reasonable accommodation must
complete and submit this request form along with supporting documentation to the Office of
Human Resources at firstname.lastname@example.org.
A confidential interactive discussion with Human Resources is encouraged for employees
who are seeking reasonable accommodations.
If more information is needed, the Institution may require that you authorize your health
care provider to confirm your disability and/or the need for the requested
It is your responsibility to ensure that your health care provider statement or other
supporting documentation is returned to the Office of Human Resources.
You are not required to disclose to your immediate supervisor the medical basis for a
requested accommodation. Medical records are confidential and maintained in the Office
of Human Resources only.
To request assistance with the process or form, please contact Vicky Smith, Executive Director of
Human Resources at email@example.com.
Employee Name: Employee ID #:
Employee Job Title: Employee Department:
Home Phone Number: Cell Phone Number:
Supervisor Name: Supervisor E-mail:
This is a (choose one): New request for accommodations Request for an extension and/or alteration
of existing accommodations*
Physician confirmation may be required.
Anticipated Begin Date of accommodations: __________
Expected end date of accommodations:____________
NATURE OF THE QUALIFYING DISABILITY/PUBLIC HEALTH EMERGENCY (Select all that
What physical or mental impairment have you been diagnosed with by your physician(s) that require ADA
What underlying medical condition or CDC defined status puts you at a greater risk for severe illness related to
the public health emergency?