Fillable Reasonac Reasonable Accommodation Request Form (City of Phoenix)

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Reasonac Reasonable Accommodation Request Form (City of Phoenix)

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Human Resources Department
Reasonable Accommodation Request
To request a reasonable accommodation during the testing process, please complete this form and email to
hrc@phoenix.gov. Hard copies can be submitted to the City's Human Resources Center. If you have questions,
please call one of the numbers listed above.
Name (please print): _______________________________________________________
Last Name, First Name, Middle Initial
Phone: _________________________
Email: ________________________________________________________
I have applied for (Job Title, Job ID#, Exam Date): __________________ __
a
nd may need reasonable accommodation during the testing process. Please contact me regarding this request for
reasonable accommodation. The reasonable accommodation I may need is:
I authorize the City of Phoenix Human Resources Department to contact the medical professional, agency official, or other
individual below to verify a reasonable accommodation is legitimate and necessary. I also authorize the medical
professional, agency official, or other individual who is contacted to provide the information necessary for the Human
Resources
Department to make a decision regarding my request.
Medical Professional or Agency Official Information:
Name & Job Title: _______________________________________________________________________________
Name of Agency: _____________________________________ Phone: _________________________________
HUMAN RESOURCES DEPARTMENT USE ONLY
_____ Approved _____ Denied
Comments: ________________________________________________________________________________________
_________________________________________________________________________________________________
Processed By: _______________________________________________ Date: ___________________________
Call: 602-495-5700
TTY: 7-1-1 Friendly
Talent Acquisition, Human Resources Department, 251 Wes
t Washington Street, Phoenix, Arizona 85003
Revised 04/2017
Date: ________________
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Reasonac Reasonable Accommodation Request Form (City of Phoenix)

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Completed 14 July 2020

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