| UW-MADISON ACADEMIC
STAFF
DISABILITY ACCOMMODATION
REQUEST FORM
(Confidential)
Procedures for requesting an accommodation
| 1. Division,
School, or College |
2. Divison
(or other secondary unit) |
Section I: Employee (Complete Section I only. Submit entire
form to supervisor.
| 3. Position
Title |
4. Date
of Request |
FOR INFORMAL REQUESTS, GO TO 9. BELOW
7. My disability is (e.g., visual impairment, arthritis.):
____________________________________________________________
____________________________________________________________________
____________________________________________________________________
8. My disability impairs my ability to perform assigned job duties
in the following way (attach additional pages if necessary)
:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
9. The reasonable accommodation I am requesting is (attach additional
pages if necessary):
___________________________________________________________
____________________________________________________________________
____________________________________________________________________
Section II: Employer (Refer to campus Academic
Staff Disability Accommodation Policy.)
10. Accommodation Request Decision:
-
[] Approved
-
[] Denied
-
[] Modified
11. (If modified or denied, attach a description of the modification
and provide rationale for modification or denial.)
______________________________________________________________
____________________________________________________________________
____________________________________________________________________
| 12. Name
of person making decision |
13. Cost
of accommodation
|
| 14. Signature
|
15. Date
|
Original - Equity & Diversity Resource Center, Copy
1 - Employee, Copy 2 - Division/College/School Confidential
File
|
