Employee Accommodation Request Form

Employee Information

Please enter your information

First Name

Last Name

Middle Name

Preferred Name

Preferred Pronouns

Gender

Emory ID

If Emory ID is not applicable:

If you do not have an Emory ID number, please enter n/a in the ID field, and confirm by checking the box below.

Indicate Your Employee Affilliation

Which of the following is applicable?

Please use your Emory issued email address

Phone Number

Indicate your preferred method of communication

Supervisor Name

Supervisor Email Address

Human Resources Contact Name (if known)

Specific Disability and Accommodation Information

Disclaimer:

Any private health information (PHI) shared in this request form and any supporting clinical documents will remain private and will only be used for the purpose of coordination of ADA accommodations. PHI shared with Emory's Department of Accessibility Services will not be shared with the employee's department or human resources.

Describe the nature of your disability.

Include any diagnoses associated with the accommodation request that have been confirmed by a healthcare provider.

How is your disability/impairment associated with the accommodation you are requesting?

Are you requesting a workplace accommodation?

Are you requesting a parking accommodation?

Supporting Documentation

Disclaimer: Any documentation submitted will only be viewed and securely stored by Emory's Department of Accessibility Services.

Have you already requested or obtained documentation from your healthcare provider to support this accommodation request?

If you are unable to upload supporting documentation to this form, please email it to dasemployee@emory.edu or fax it to 404-727-1126.

Do you currently have access to an online patient portal where you can access your health records?

If yes and you do not have other documention to submit with your request, please submit any health record that includes the diagnosis associated with the accommodations you are requesting. (i.e. screenshot, PDF of print out, etc)

Upload supporting document(s)

For workplace accommodation requests, please have your provider complete the Medical Inquiry Form.

For parking accommodation requests, please have your provider complete the Parking Medical Form.

If your provider is submitting a letter in lieu of a form, the documentation requirements can be found here.

Employee Accommodation Request Form

Employee Information

Specific Disability and Accommodation Information

Supporting Documentation

Document Information