UW-MADISON FACULTY
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 department chair or executive committee.

3. Faculty Rank

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 Faculty Accommodation Policy Under Americans with Disabilities Act)

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 - Dept. Executive Committee Confidential File