STATE OF GEORGIA

[Agency Name]

REASONABLE ACCOMMODATION REQUEST

[Agency] Action Checklist

Essential functions list attached: ☐ Yes ☐ No

If list not attached, please explain why.

Reasonable Accommodation Request Form given to employee on

Click or tap to enter a date.

Completed Reasonable Accommodation Request Form received from employee on Click or tap to enter a date.

If necessary, Request for Documentation Form submitted to health care

professional on Click or tap to enter a date.

If necessary, completed Request for Documentation Form received from

health care professional on Click or tap to enter a date.

Agency action taken:

☐Requested Accommodation approved on Click or tap to enter a date.

☐Requested Accommodation denied on Click or tap to enter a date.

☒Other action taken (explain below) on Click or tap to enter a date.

Notification to employee concerning action taken on Click or tap to enter a date.

See also: http://www.eeoc.gov/eeoc/internal/reasonable_accommodation.cfm