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Notice of Potential Need for Accommodation


 

Thanks for contacting us today!

This form is intended to provide us with important information about your potential need for reasonable accommodation(s) to perform the essential functions of your job.

Please take a moment to complete the questions and when finished, a copy will be forwarded to the HR team. Once received, a member of the team should contact you within 1 to 2 business days to discuss.

If you have any questions in the meantime, please don't hesitate to contact HR.

 

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1.  

Company name:
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2.  

Workplace address:
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  • State/Province
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
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  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana (MT)
  • North Carolina
  • North Dakota
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
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  • New York
  • Ohio
  • Oklahoma
  • Oregon
  • Pennyslvania
  • Puerto Rico
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
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  • Virginia
  • Virgin Islands
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
â–¼
  • United States
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3.  

First and last name
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4.  

What is your title/position?
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5.  

Please provide the best email address in which to reach you.
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6.  

Please provide the best phone number in which to reach you.
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7.  

Please provide the name and title of your immediate supervisor/manager.
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8.  

Can you provide documentation from your healthcare provider indicating your need for accommodations, limitations, or modifications to your job?
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9.  

Please provide us with an overview of the limitations (or necessary modifications) that have been established by your healthcare provider.
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10.  

Please provide the start date for the limitations/modifications.
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11.  

If available, please provide the estimated duration or end date of the need for modifications (or limitations), as directed by your healthcare provider.
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12.  

If you have documentation available, please upload it here.

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