Date: ________________________
Employee's Name: __________________________________________________
Phone: ________________________ Email: _________________________
Job title: _______________________ Department: ____________________
Supervisor's name: __________________________________________________
Describe the nature, extent and duration of your disability:
____________________________________________________________________
____________________________________________________________________
Describe the accommodations you believe are needed to enable you to perform the essential functions of this job. (Be as specific as possible, for example adaptive equipment, reader, interpreter, training, schedule change, etc.)
____________________________________________________________________
____________________________________________________________________
If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore?
____________________________________________________________________
____________________________________________________________________
Provide the name, address, telephone and fax numbers of your health care provider. The provider may receive a request from us for information regarding your impairment/disability and recommendations for accommodations.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Attach any supporting documentation that may be helpful in evaluating this request for accommodation.
I authorize the release of information regarding my disability to [Company name} management as deemed necessary by human resources to facilitate this request for accommodation.
Employee signature: ________________________________________________
Date: _____________________________________________________________
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