Knox College Accommodation Request Form

What type of accommodation(s) do you need?*

Modified work scheduleChange in procedurePurchase Assistive DeviceRemoval of Communication BarrierPurchase of Assistive ServicesRemoval of architectural barrierJob RestructureReassignmentOther
Please describe the accommodation requested:*
Please explain how you believe this accommodation will enable you to perform the essential functions of your position:*
Please identify the essential duties (do not include marginal duties) of your position:

I hereby certify that I believe I am a qualified individual with a disability as defined by the law. I require an accommodation to perform the essential functions of my position. I understand that a detailed review of my disability status may be required, and I agree to cooperate fully in this process. I further understand that if my request is granted, I am obligated to report any changes in my disability status which may require a re-evaluation of this request. Granting of this request does not signify approval of any future reasonable accommodation request for any other position within the College.
Signature:

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Date:

MonthDayYear
Date
Time:

:HourMinutesAM/PM Option
For additional information, please contact Office of Human Resources at 309-341-7200.
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