Please complete this form if you have a physical or mental health disability and need a reasonable
accommodation to perform the essential functions of your job with Oral Roberts University. Should you
need any help completing this form, or if you have any questions about this form or ORU’s reasonable
accommodation policy/process, please contact ORU’s Human Resources Department at (918) 495-7163.
Once completed, this form should be submitted to
EMPLOYEE/APPLICANT NAME: _______________________________________________________
EMPLOYEE Z NUMBER: ________________________________________________
DEPARTMENT: _______________________________________________________________________
POSITION/JOB TITLE: _________________________________________________________________
1. Please describe the accommodation(s) you are requesting. If there is more than one accommodation that
you believe will meet your needs, please describe all possible accommodations.
2. Please describe your medical condition and the reason(s) why you are requesting an accommodation.
For current employees, include a description of the essential functions of your job that you currently are
unable to perform, and explain how the requested accommodation(s) will enable you to perform those
essential functions of your job.
3. For how long will the requested accommodation(s) be needed? ______________________________
4. Please attach to this form any documentation that you believe supports your need for the requested
reasonable accommodation. Please also provide any other information that you believe is relevant to
your request.
Employee/Applicant Signature Date
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