Employee ADA Accommodation Request Form

Name*

First NameLast Name

Mid Mich Email*

example@midmich.edu

Title*

Enter the title of your role at Mid Michigan College.

Select Your Department*

Select your department from the drop down list or select other.

Enter the name of your department.*

Since your department was not listed, enter it here.

Supervisor's Name*

First NameLast Name

Supervisor's Mid Mich Email*

example@midmich.edu

Describe the nature, extent, and duration of your disability.*

Be as specific as possible.

Describe the accommodations needed to enable you to perform the essential functions of your position.*

Be as specific as possible.

Attach documentation of your disability and any other supporting materials related to this request.

Browse Files

pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

My signature below authorizes the release of information regarding my disability to Mid Michigan College as deemed necessary by Human Resources to facilitate this accommodation request. I also attest to the fact I have access to a copy of the position job description for my reference.

Signature*

Date*

MonthDayYear

Significant effort has been made to ensure this content meets accessibility guidelines. If you encounter a barrier you can report the barrier at midmich.edu/reportaccessibilitybarrier or contact Strategic Communications at (989 386-6622 x579 or stratcomm@midmich.

In its commitment to providing a safe environment, Mid Michigan College actively endeavors to broaden our diversity, promote equal opportunity, and prohibit any form of discrimination in its programs, activities, and conditions of admission or employment. Learn more about these efforts and policies by visiting midmich.edu/eeo, midmich.edu/titleix, and midmich.edu/securityreport.