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Request for Reasonable Accommodation

April 1, 2000
Related Topics: Disabilities, Featured Article
The employee completes this form to make their accommodation needs known to the employer.



Applicant (     )     Employee (     )

Name: _______________________

Date: ________________

Position: _______________________

Dept.: ________________

This information is voluntary and will in no way influence an employment decision. If you are an individual with a disability who needs an accommodation, _________________ is committed to providing reasonable accommodation to qualified individuals to help them participate in pre-employment testing and/or perform the job satisfactorily and safely. Please assist us by completing this form and specifying any accommodation you may need. Your information will be kept confidential and used in compliance with applicable law and _______________________ policy on Reasonable Accommodation.

Describe the limitation(s) or condition that this request is based on:

Do you require assistance for pre-employment testing?
      Yes or No
If yes, please specify what accommodation you require:

Which essential job task or tasks are you unable to perform without reasonable accommodation?

Which marginal job task or tasks are you unable to perform?

Identify any accommodation that would assist you in performing the essential job tasks in question. (This can include special equipment or methods, changes in the physical layout, etc.)

The information and forms contained in this feature are intended to provide useful information on the topic covered, but should not be construed as legal advice or a legal opinion.

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