Workplace Accommodation Request

As we begin the interactive process to review your request for an accommodation, it will be helpful for you to provide the information requested below. After the information is received, Ms. Franklin will follow up with you directly and provide you the opportunity to further dialogue about your request and seek any additional clarification.

Please know that all information will be treated confidentially and carefully considered under the Americans with Disabilities Act. Your wellbeing in the workplace is important to us.

These questions are designed to identify how workplace accommodations might assist you in meeting the essential functions of your job.

Name

Title/Position

Email Address

Describe the limitation interfering with your ability to perform the essential functions of your job or access an employment benefit:

Have you had any accommodations in the past for this same limitation?

- Select -YesNo

If Yes, please describe the accommodations:

What, if any, job function or functions are you having difficulty performing?

What, if any, employment benefit are you having difficulty accessing? Example: participating in training or meeting opportunities.

What specific accommodation are you requesting that will allow you to meet the essential functions of your job?

Please provide any additional information that might be useful in processing your accommodation request

Signature & Date