Temporary Workplace Adjustment/ Reasonable Accommodation Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Individuals who are employed at Converse College and are requesting reasonable accommodation(s) under the Americans with Disabilities Act of 1990 (ADA) and the ADA Amendments Act of 2008 (ADAAA) are encouraged to complete this form in its entirety. If you are unable to complete this form on your own, someone else may complete the form on your behalf. Completed forms are to be submitted and reviewed by the Director of Human Resources.

The College has approved is continuing the temporary workplace adjustment for requests that do not align with ADA reasonable accommodation guidance.

****All submissions FACULTY should be sent asap for the fall term to be reviewed.

Human Resources will accept documentation for temporary workplace adjustments and ADA requests that include a diagnosis such as a health insurance claim/benefits form, health care visit summary, or other medical records within the last two to three years documenting the condition in lieu of a signed health care provider evaluation form from a treating provider. Treating providers and employees are highly encouraged to scan/photograph and email supporting documentation to hr@converse.edu to ensure timely receipt and processing.

Email *

Accommodation Request Date *

YYYY

Name *

Department *

Position Title *

Supervisor's Name and Title *

Clear form

Never submit passwords through Google Forms.

This form was created inside of Converse University.

Does this form look suspicious? Report

Forms