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Staff Accommodation Form
Staff Accommodation Form
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Employee's Name
*
Email
*
Phone
*
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:
*
Provide the name, address, telephone and fax numbers of your healthcare 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.
Click or drag a file to this area to upload.
Signature
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Clear Signature
Date
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Submit
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