Reasonable Accommodation Request Form For Employees - University Of Connecticut
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2University of Connecticut
Reasonable Accommodation Request Form For Employees
Revised 10/13
All information regarding an individual's medical condition and the reasonable accommodation request is confidential and only disclosed to persons
on a need to know basis. Any and all documents related to this request are kept confidential and will be maintained and used in accordance with
applicable state and federal law.
Faculty
Employee/Staff
Other (specify) __________________
Instructions: Individuals who are
employed at the University of Connecticut
Name: ______________________________________________________________
and are requesting a reasonable
First
Middle
Last
accommodation(s) under the Americans
with Disabilities Act of1990 (ADA), Section
Job Title: ___________________________________________________________
504 of the Rehabilitation Act, relevant
state law, and accompanying state and
Department: _________________________________________________________
federal regulations, are encouraged to
complete this form in its entirety.
Work Address: _______________________________________________________
City
State
ZIP Code
In order to explore possible coverage and
reasonable accommodations, information
Work Telephone Number: ______________________________________________
is required regarding your medical
condition, essential job functions,
Work Email: _________________________________________________________
applicable functional limitations and your
requested accommodation(s). It is often
Home Address: _______________________________________________________
necessary for staff of the Office of
City
State
ZIP Code
Diversity and Equity to discuss your
medical condition and the documentation
Home Telephone Number: ______________________________________________
you submit to our office with providers
such as licensed physicians,
Home Email: _________________________________________________________
psychologists, or other qualified
Home Email
professionals.
If you need help in
Preferred method of contact:
Home Phone
Work Email
completing this form, someone else may
Work Phone
complete it on your behalf, or you may
contact the Office of Diversity and Equity
How long have you worked/studied in current position? _______________________
for assistance. For Storrs and Regional
campuses call (860)486-2943.
How long have you worked/studied at UConn? ______________________________
Supervisor's Name: ___________________________________________________
Upon completion, please forward this
First
Middle
Last
form, along with the Medical Release
Form, to the Office of Diversity and Equity.
Job Title: ____________________________________________________________
Make sure you sign both forms.
Department: _________________________________________________________
For Storrs and Regional campuses:
Office of Diversity and Equity
Work Telephone Number: ______________________________________________
University of Connecticut
241 Glenbrook Road - Unit 4175
Work Email: _________________________________________________________
Telephone - (860) 486-2943
Facsimile - (860) 486-6771
Section B:
Medical Information
Email - ode@uconn.edu
Please identify the medical condition(s) for which you are requesting an accommodation.
Web:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_____________________________________________________________________
Please provide the name and contact information for the health care professional who
diagnosed the medical condition(s) listed above. Please include the date of diagnosis.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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