Georgia Institute of Technology

EMPLOYEE ACCOMMODATION REQUEST FORM

Reasonable accommodations may be needed to provide equal access and opportunities to qualified individuals with disabilities. If you are a University employee with special needs that are the result of a disability and you believe that reasonable accommodations will assist you in the performance of your job, please complete this form and return it to the address listed at the bottom of the page.

 

Requestor's Information

 
 
 

This is a 9-digit long identification.

 
 
 
 
Phone
 
Phone
 
 

Please include days and hours.

 
 

Supervisor Information

 
 
 
Phone
 
 

Details for Reasonable Accomodation Request

Please try to limit each of your responses to 1,500 characters or less, this includes spaces.

 
 
 
 

i.e. If you are requesting a piece of equipment or a device, please provide a description, manufacturer, cost, where to order, etc.

 
 
 
 
 
 
 
  1. Medical Certification Form/Detailed Medical Statement
  2. Voluntary Self-Identification Form


You may also attach any additional information pertinent to your reasonable accommodation request.

Drop your files here
 
 

I give the Georgia Institute of Technology permission to explore coverage and reasonable accommodations under the Americans with Disabilities Act. This may include speaking to appropriate University personnel and/or my health care professional. I understand that all information obtained during this process will be maintained and used in accordance with ADA confidentiality requirements. I further understand that I will be required to provide appropriate documentation of my disability, including the impact of the functional limitations on my ability to perform the essential functions of my job.