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EMPLOYMENT ACCOMMODATION REQUEST FORM


The following information is needed if you wish to make a formal request for a specific employment related accommodation. All requests are treated as confidential information and will be considered on a case-by-case basis.

Reasonable accommodations are defined as those changes or adaptations necessary for employees with qualifying disabilities to perform essential job functions. As an employer, San Francisco State University is responsible for providing reasonable accommodation, in accordance with provisions contained in the Americans with Disabilities Act (ADA) as amended, Section 504 of the Rehabilitation Act, and the Fair Employment and Housing Act (FEHA). In most cases, you will be asked to provide documentation of your disability from a qualified medical professional. DPRC may also request a copy of your position description of record in order to determine with you which essential functions need accommodating. For more information, visit the Employee Accommodations website.
Personal Information
  5. Hint: Enter 9 numeric characters (ex. 900012345)
Contact Information
  1. Hint: Enter 10-digit number only.
  2. Hint: Enter 10-digit number only.

Questions

  1. What is your preferred method of contact? *
  3. Please indicate your employee type *
  7. Disability Duration: *
  8. Have you requested accommodations from your direct supervisor? *
  9. Have you applied for or using any disability leave programs through Human Resources such as Non- Industrial Disability Insurance (NDI), Family and Medical Leave (FML), etc.? *
  10. Do you have an open or pending Worker's Compensation claim for this/these condition(s)? *

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