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Workplace Accommodation Request Form

This form is used to notify the benefits team that a member of our staff or faculty may need a workplace accommodation for themselves or for the care of a family member. The Americans with Disability Act (ADA) and other state legislation allows for employees to self-identify need for accommodations if they are in a high-risk category for Covid-19 based upon a preexisting medical conditions or disability or if they are the primary care provider to someone who is in a high-risk category. Accommodations are determined by the needs of the individual employee in consultation with their medical provider and HRDI. This form should be submitted by the employee.

Employee Information:

Name:

Department:

Bargaining Unit or Union:

Email:

Home Phone Number:

Campus Phone Number:

Supervisor:

Have you spoken to your supervisor about this need?

Yes
No

Is there any other information you want to share at this time?