EMPLOYEE IDENTIFICATION
Employee Name	Employee ID
Division/Work Unit	Employee Job Title
Reason for request (check one) Disability Religious belief or practice

ACCOMMODATION
Identify the job function, benefit, or term/condition of employment for which accommodation is needed
Identify the medical condition or religious belief/practice that restricts your ability to perform, participate, or adhere
Describe how the job function is affected by the disability or religious belief/practice
Identify the requested accommodation (Please be as specific as possible)
Identify alternate solutions that should be considered
Attach any available supporting information/descriptions that will clarify the request unless disability is obvious.
Are you attaching additional documents? Yes No If yes, how many pages?

EMPLOYEE ACKNOWLEDGEMENT
My signature below certifies that information provided above is true and correct to the best of my knowledge. I understand that I should submit this completed form to XXXXXXXXXXXX and that information on this form is confidential, and will be used only in relation to this request.
Signature	Date

APPROVING OFFICIAL ACKNOWLEDGEMENT
My signature below certifies that I received and forwarded this request as dated.
Date Received	Date forwarded to Human Resources
Approving Official Name	Signature

Approving Official is to send completed form & supporting documents to:

Human Resources

Address

City State Zip Code

FAX: XXX-XXX-XXXX

For additional information or assistance, you may contact Human Resources at XXX-XXX-XXXX.