UW-MADISON CLASSIFIED 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

5. Name

6. Signature

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 Classified 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 [] Estimate [] Actual
14. Signature	15. Date

After employer completes Section II, distribute as follows:

Original - Equity & Diversity Resource Center, Copy 1 - Employee, Copy 2 - Division/College/School Confidential File Copy 3 - DER/DAA (Employee Identification blinded)