Workplace Adjustment Notice Request Form
Submit your workplace adjustment request to help us create a supportive and productive environment.
Full Name
*
First Name
Last Name
Work Email Address
*
example@example.com
Department
*
Please Select
Human Resources
Finance
IT
Operations
Sales
Marketing
Other
Job Title
*
Manager or Supervisor Name
Type of Adjustment Requested
*
Please Select
Flexible Working Hours
Remote Work Arrangement
Ergonomic Equipment
Workspace Modification
Assistive Technology
Other
Please describe the adjustment you are requesting
*
Reason for Request (do not include sensitive or medical information)
*
Preferred Adjustment Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments (optional)
Submit Request
Should be Empty: