ADA Reasonable Accommodation Request Form

Employee’s Name:

Date:

Phone:

Employee E-mail:

Job title:

Department:

Supervisor:

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 health care provider. The provider may receive a request from us for information regarding your impairment/disability and recommendations for accommodations.

Authorization / Employee signature:

I understand that typing my full name in this box constitutes a legal signature. I authorize the release of information regarding my disability to UA - Pulaski Technical College Human Resources and management as deemed necessary by human resources to facilitate this request for accommodation.