Accommodation Request Form

 
1 Start 2 Preview 3 Complete

Full assistance shall be provided to any applicant/employee seeking to utilize this formal process of request for reasonable accommodation. The individual requesting shall have the opportunity for a thorough discussion with Jacquie Kittler, Assistant Director of HR, when these forms are provided.  This form may be used by any employee seeking accommodation, by any applicant or employment seeking accommodation during the application/selection process, and by any other person seeking, other than students, accommodation in conjunction with his or her participation in any of UMass programs, services or activities, including employment. 

The purpose of providing reasonable accommodation is to enable a person with a disability to perform the essential functions of the job.  Therefore, information is necessary to determine:

  1. Whether the requestor actually requires a reasonable accommodation, and
  2. The nature and extent of the accommodation, if one is required.

This information will be used only for the purpose of taking voluntary action to overcome the effects of conditions limiting opportunities for persons with disabilities. Although the information is being requested on a VOLUNTARY basis and will be kept CONFIDENTIAL, your failure to provide us with sufficient information necessary for us to make a reasonable accommodation determination may result in a decision that does not adequately address your needs.

Questions to clarify accommodation request.
Questions to document the reason for accommodation request.