Employee Request for Reasonable Accommodation

Employee Name	Classification	Date of Request


Division	*Statement of Disability (Attach medical 
	  statement if requested by manager)


*    Attach additional sheets for questions below if necessary.
1.  	Type of accommodation requested to perform essential functions:






2.  	Which essential function(s) of your job will the requested accommodation allow to perform?




3.  	Why is the requested accommodation necessary to perform the essential job function(s)?




4.  	How will the requested accommodation be effective in allowing performance of the essential job function(s)?




5.  	Are there any marginal functions that can be eliminated?



Signature of Employee	Date

Signature of Supervisor	Date

Signature of Manager	Date

Additional Comments: