Accommodation Request Form The University of North Carolina at Chapel Hill is committed to equal opportunity in all aspects of employment for qualified disabled individuals. The purpose of this form is to assist the University of North Carolina at Chapel Hill in determining whether, or to what extent, a reasonable accommodation is necessary for an employee with a disability to perform one or more essential functions of his or her job safely and effectively. The information you provide will be kept confidential consistent with State and Federal law. Please note that supervisors and managers may be informed regarding necessary accommodations; health and safety personnel may be informed if the condition might require emergency treatment; and government officials investigating compliance with applicable laws may be informed. This form must be filed the Self-Identification of Disability form. in addition to Employee Information: Name: Gender: Male Female Department/Unit: Position/Title: Employment Status: EPA SPA Permanent Temporary Phone # (Work): PID #: Phone # (Home/Cell): Email Address: Mailing Address (Please include CB# if office address): Supervisor: Phone #: HR Rep: Phone #: Current Work Schedule/Shift: Former/Existing Accommodations: University Offices Contacted: Date of Hire:
Accommodation Request Form The University of North Carolina at Chapel Hill is committed to equal opportunity in all aspects of employment for qualified disabled individuals. The purpose of this form is to assist the University of North Carolina at Chapel Hill in determining whether, or to what extent, a reasonable accommodation is necessary for an employee with a disability to perform one or more essential functions of his or her job safely and effectively. The information you provide will be kept confidential consistent with State and Federal law. Please note that supervisors and managers may be informed regarding necessary accommodations; health and safety personnel may be informed if the condition might require emergency treatment; and government officials investigating compliance with applicable laws may be informed. This form must be filed in addition to the Self-Identification of Disability form. Employee Information: Name: Gender: Male Female Department/Unit: Position/Title: Employment Status: EPA SPA Permanent Temporary Phone # (Work): PID #: Phone # (Home/Cell): Email Address: Mailing Address (Please include CB# if office address): Supervisor: Phone #: HR Rep: Phone #: Current Work Schedule/Shift: Former/Existing Accommodations: University Offices Contacted: Date of Hire:
Accommodation_Request_Form.docx