STATE OF GEORGIA

[Agency Name]

VOLUNTARY REQUEST FOR

REASONABLE ACCOMMODATION

If you are a qualified individual with a disability under the ADA, as amended, you are entitled to a reasonable accommodation that does not pose an undue hardship, or substantial negative impact on the business needs of the organization. Reasonable accommodation may be requested for the following purposes:

To complete the employment application process.

To perform essential job functions.

To have the same benefits and privileges as non-disabled employees.

Generally, advance notice is required to fulfill reasonable accommodation requests. However, a response to immediate need for accommodation will be made to the fullest extent feasible. Requests for reasonable accommodations will be evaluated on a case by case basis. The reason for the requested accommodation must be directly related to and necessary because of the disability itself.

Date:	Check One: ☐ Applicant ☐ Employee

Name:	Department:

Job Title:	Work Location:

Work Phone No:	Supervisor:

Work E-Mail Address:

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STATE OF GEORGIA

[Agency Name]

Voluntary Request for

Reasonable Accommodation

Please identify the reason(s) for your accommodation request: (check applicable boxes)

☐ To complete the employment application process.

☐To perform essential job functions.

☐To have equivalent benefits and privileges as non-disabled

employees.

Please describe how your condition restricts your ability to accomplish or obtain the item(s) checked above. If related to the performance of job responsibilities, state the essential job functions for which you need an accommodation, and describe the difficulty you have performing those specific tasks.

Please describe the accommodation(s) you are requesting and explain how the requested accommodation(s) would be effective.

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STATE OF GEORGIA

[Agency Name]

Voluntary Request for

Reasonable Accommodation

Please identify any potential resources or suggestions for [agency/department] to consider in responding to accommodation requests that must be purchased or acquired.

Click or tap to enter a date.

Employee Signature Date

Please submit this completed form to [your Approving Official or Human Resources Office]. You may be required to complete an Employee Release: Documentation in Support of Request form for [agency/department] to properly evaluate your reasonable accommodation request(s). This information, if required, will be maintained in your medical records file separate from your official personnel file and will only be used to evaluate your accommodation request(s).