ADA Accommodation Form

REQUEST FOR REASONABLE ACCOMMODATION
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of request*

MonthDayYear
Date
Employee's Location*
Type of accommodation requested, if known (Be as specific as possible)*
Reason for request*
Medical Certification

Cancelof
Privacy Act Statement

The Rehabilitation Act of 1973. 29 U.S.C. section 791, and Executive Order 13164 authorize collection of this information. The primary use of this information is to consider, decide, and implement requests for reasonable accommodation. Additional disclosures of the information may be: To medical personnel to meet a bona fide medical emergency: to another Federal agency, a court. or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency when the Government is a party to the judicial or administrative proceeding: to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of the individual; and to an authorized appeal grievance examiner, formal complaints examiner, administrative judge, equal employment opportunity investigator, arbitrator or other duly authorized official engaged in investigation or settlement of a grievance, complaint or appeal filed by an employee.

EEOC FORM 557
Should be Empty:

REQUEST FOR REASONABLE ACCOMMODATION