REASONABLE ACCOMMODATION REQUEST FORM
NAME: __________________________ JOB TITLE/DEPT: _________________
TELEPHONE NO. ____________________ DATE: ________________________
I am requesting a reasonable accommodation in the workplace for my disability. Attached is documentation from an appropriate medical source establishing that I have a disability.
I am unable to perform the following essential functions of my position without an accommodation:
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I request I be provided with the following accommodations to assist me in performing the essential functions of my position:
____________________________________________________________________________
____________________________________________________________________________
The above described accommodation(s) will assist me to perform my essential job functions as follows:
____________________________________________________________________________
____________________________________________________________________________
Alternative reasonable accommodations that may be effective are:
____________________________________________________________________________
____________________________________________________________________________
______________________________________________________ / _______________
Employee/Applicant Signature/ Date
______________________________________________________ / _______________
Supervisor/Manager Signature/ Date Received
Please give this form to your supervisor. If you wish, you may also forward the completed form to the ADA Coordinator at the Office of Equal Opportunity, 609 Buena Vista NE, Albuquerque, NM 87131;505-277-5251.
Comments may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm