REQUEST FOR ACCOMMODATION FORM

Agency Name

Return completed form to Agency ADA Coordinator:

Name

Phone #

Fax #

CONFIDENTIALITY STATEMENT: A request for accommodation, including medical and other relevant information, is privileged and may only be released as appropriate to individuals with a business need to know. (Rev. 4/2025)

Section 1: Requestor Information

Requestor's Name

Requestor is

If Requestor is an employee, also provide the following:

Job Title

Division/Unit

Supervisor's Name

Requestor's Email Address

Requestor's Phone Number

Section 2: Requested Accommodation

Please describe the nature of your disability, including any functional limitations caused by the condition.

Select the type of accommodation requested

Describe the accommodation(s) requested. Please provide detailed information to support the request.

for ex., job duties for which accommodation is requested, date/time location of interview for which accommodation is requested, name of the program or facility to which access is needed.

This request is for the time period (day, month and year)

From

Requestor's Signature

Date

Section 3: To Be Completed by Agency ADA Coordinator

A. Process Tracking

1. Date the Request for Accommodation was signed by Requestor
2. Date the Request for Accommodation was received by ADA Coordinator
3. Date of initial contact with Requestor (initiated interactive process)
4. Date(s) of follow-up contact with Requestor
5. Date the Request for Accommodation was discussed with Appointing Authority
6. If applicable, date alternative accommodation(s) was discussed with Requestor
7. Date Requestor was notified of final accommodation determination
8. Date Requestor was notified of internal grievance procedure

B. Is there an alternative accommodation(s), other than the one requested, that would satisfy the request?

Yes

If yes, please identify

C. Was an accommodation granted?

Yes (Proceed to section D. below)

No (Proceed to section F. below)

D. Accommodation Granted

Was the accommodation granted the same as the one requested?

Yes

If an alternative, equally effective accommodation was granted, explain the reason this option was selected rather than the one requested.

(Reason for alternative accommodation should be fully documented.)

E. Authorized Duration of Accommodation

From

F. Denial of Accommodation

Select reason for denial and provide further explanation below.

(Denials should be fully documented.)

Further explanation

ADA Coordinator's Signature

Date