Employee Accommodation Request Form

If this is an urgent issue, please call the hotline number at 312-476-3232 or EmployeeRelations@depaul.edu.

What is your full name?*

Title*

Phone*

Email*

Department*

Manager*

Types of Accommodation Requested?*

Disability or medical condition

Pregnancy, Childbirth or related condition

Identify any physical or mental impairment that is the basis of your request for reasonable accommodations?*

Please describe how any limitations resulting from the impairment interfere with your ability to perform the essential function(s) of your job.*

What job function are you having difficulty performing?*

Please provide the name, address, phone, and email information of the healthcare provider who will certify your need for accommodation. You will need to give the healthcare provider a copy of your job description and have the provider complete and sign the Healthcare Provider Certification Form and return it to the ER&EEO team.*

List the specific accommodation(s) you are proposing?*

Describe how the proposed accommodation(s) you are requesting will enable you to perform the essential function(s) of your job.*

How long do you believe you will need the requested accommodation(s)?*

Additional Comments: *

Employee Signature*