Disability Accommodation Review Form

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 of reviewer:_________________________________________________Please print

Signature of reviewer: ___________________________________________________  Date:  ______/______/______