Faculty/Staff/Applicant Reasonable Accommodation Request Form
The purpose of this Reasonable Accommodation Request Form is to assist Oakland University's respective to determine whether, and to what extent, a reasonable accommodation for a faculty, staff, or applicant with a disability is necessary. This information will be kept confidential and shared only with those directly involved and on an as needed basis. Information may also be provided in emergency situations to medical personnel assisting the faculty or staff member or as required by law. Faculty, Staff, and applicants for employment should complete this Reasonable Accommodation Request Form.
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Email *
Faculty/Staff/Applicant Name: *
Date:
MM
/
DD
/
YYYY
Title:
Department:
Supervisor:
What are the essential functions of this position? If needed, please attach the job description.
What specific accommodations are you requesting and why? (If you are not sure what accommodation is needed, do you have any suggestions about what
options we can explore?)
What, if any, job function are you having difficulty performing?
Have you had any accommodations in the past for this same limitation?
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If you have had any accommodations in the past for the same limitation, what where they?
I give Oakland University permission to explore possible coverage and reasonable accommodations
under the Americans with Disabilities Act of 1990 and the regulations promulgated thereunder as
they may be amended from time to time. I understand all information obtained will be used in
accordance with ADA confidentiality requirements.
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Please type your name as your signature.
Please provide your email and phone number.
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