Employee Reasonable Accommodation Request Form

Human Resources
111 University Parkway, Suite 100
Yakima WA 98901
Phone: 509-452-5100
Fax: 509-452-5101

Human Resources is the point of contact for employees who need to discuss accommodation for a disability. Employees who have a disability may be entitled to a reasonable accommodation under state or federal law. Individuals requesting a reasonable accommodation for a disability are encouraged to provide as much information as possible so that Pacific Northwest University (PNWU) can evaluate the request and provide reasonable appropriate aids, services or other reasonable accommodations. We ask that you (or another person on your behalf) complete this form, or provide the requested information in a different format, and provide that information along with supporting documentation to hr@pnwu.edu. Additional information may be requested after PNWU's evaluation.

All information shared with the University through the evaluation and/or reasonable accommodation process will be treated as confidential and maintained in accordance with legal requirements.

Full Name*

First NameLast Name

Today's Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email*

Phone Number*

Area CodePhone Number

Preferred Method of Contact*

Department / Unit*

REASONS FOR REQUESTING ACCOMMODATIONS

Please respond to the following questions regarding the diagnosis(es) for which you are requesting accommodations.

Type of Accommodation *

Please identify the specific diagnosis(es) related to your request for accommodations. *

Date(s) of Diagnosis (es)*

1. Explain how your impairment affects your ability to perform the essential functions of your job*

2. List the accommodation(s) you are requesting. Please be as specific as you can.*

3. Add any comments you feel may be helpful in our consideration of your request.

4. Unless the disability and need for a reasonable accommodation is obvious that no medical document is needed, please include medical verification of the impairment(s

Medical Documentation

Upload a File

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Signature*

First NameLast Name

Date Submitted*

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