Employee Disability Accommodation Form

Part I: Individual requesting/needing reasonable accommodation (to be completed by the employee)

Name:
Department:
Classification Rank/Title:
Supervisor’s Name:
Phone:	Date:

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Part II: Essential functions of the position (to be completed by the supervisor)

Essential Functions	No Accommodation Needed	Accommodation Needed

What evidence or documentation exists to support the need for an accommodation based on disability?

Duration of accommodation: to .

Date	Date
Physician	Occupational Therapist
Counselor/Psychologist	Vocational Rehab. Counselor
Physical Therapist	Other
Other

Part III: Accommodation(s)/modification(s) implemented (to be completed by the supervisor)

Essential Functions	Accommodation(s)	Date	Review Date
Approximate cost analysis:

Employee	Date

Program Director	Date

Superintendent or Designee	Date

Review timeline:	Monthly	Bi-monthly	Semi-annually	Annually	Next review date

Distribution:	Employee

Supervisor

Personnel Administrator	Revised: 10/26/16