Name of employee  requesting accommodation: ___________________________________________________________Please print Name of individual completing this form: ___________________________________________________________Please print Date of initial request: ______/______/______  Date of review: ______/______/______ Accommodation requested: _________________________________________________________________________  ______________________________________________________________________________________________________ Reason for accommodation: ________________________________________________________________________ Essential function(s) affected: _______________________________________________________________________ ______________________________________________________________________________________________________ Is accommodation requested unreasonable?      YES    NO Will the accommodation pose an undo hardship on the organization?    YES    NO If no to both will the accommodation be provided?     YES     NO If no, why not: _________________________________________________________________________ If yes to either of the above what is the suggested alternative accommodation: ______________________________________________________________________________________________________ If an accommodation is offered when will it begin and for how long will it be provided? Start date: ______/______/______  End date:  ______/______/______ Date scheduled for follow up: ______/______/______ Name […]