Disability Accommodation Termination Notice
Submit this form to formally notify and document the termination of a previously granted disability accommodation.
Employee Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Employee Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer/Organization Name
*
Department or Work Location
Employee Position/Title
*
Type of Accommodation Being Terminated
*
Please Select
Physical Accessibility (e.g., ramps, elevators)
Modified Work Schedule
Assistive Technology/Equipment
Remote Work Arrangement
Modified Duties
Other
Describe the Accommodation Being Terminated
*
Reason for Termination of Accommodation
*
Please Select
Accommodation No Longer Needed
Change in Employment Status
Change in Job Duties/Requirements
End of Temporary Accommodation Period
Other (please specify below)
If 'Other', please specify reason for termination
Effective Date of Termination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload Supporting Documentation (if applicable)
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Additional Comments or Information
Signature of Recipient (Employee or Representative)
*
Submit Notice
Submit Notice
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