Reasonable Accommodation Agreement

* *	This form is to be completed by the Human Resource Director after the reasonable accommodation decision has been made.  The signatures on the bottom of this form indicates an agreement between the employee and the Department to the specific accommodation.

Name of Employee		Name of Division  Manager

The request for reasonable accommodation to the needs of the above named employee with a disability was:

	r ACCEPTED			r DENIED

Justification for the decision (indicate specific factors considered)




	
If reasonable accommodation was approved, was the employee's suggestion accepted?

	r Yes	r No	r Partially

REASON:





DESCRIBE specific accommodations to be made.




	
Cost Estimate:
	
I have read the employee request for reasonable accommodation.  I understand that all tangible accommodations purchased by the Department will become the Property of  company XYZ.

Signature of Employee	Date

Signature of Supervisor	Date

Signature of Human Resource Director	Date