Craft Health Request for Reasonable Accommodation

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This is a confidential form and will be submitted by the requesting applicant/employee directly to Human Resources

Name

First

Middle

Last

Work phone number or home telephone

Position

Supervisor

Nature of the qualifying disability

Requested/suggested accommodation (Please describe the accommodations you believe are needed to enable you to perform the essential functions of this job)

Physician name. The physician may receive a letter/fax from us requesting information on your impairment/disability and recommendations for accommodations.

First

Last

Physician address

Address Line 1

Address Line 2

City

State

Zip Code

Physician phone number

Physician fax number

I authorize the release of necessary confidential medical information regarding my disability to relevant managers as deemed necessary by Human Resources. I also attest to the fact that a copy of the position description has been given to me for review and reference. I understand that by typing my name below and clicking on "Submit", I am electronically signing this document and am certifying that the above information is true and correct.

Date

[In non-physician review cases, decisions regarding accommodations will be made within 10 days of the receipt of this form by Human Resources. Due to delays that may be caused in communications with physicians, no specific decision date can be provided for physician review cases.]