Georgia Institute of Technology EMPLOYEE ACCOMMODATION REQUEST FORM

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

First Name*

Last Name*

GT ID*

This is a 9-digit long identification.

Job Title*

Department in Administration & Finance*

Department in the Office of the Provost*

Education and Learning

Enrollment Management

International Initiatives

Library

Department in Research*

Department in Student Engagement and Well-Being*

Campus Services: Dining

Campus Services: Housing (HRL)

Campus Services: Campus Recreation Center

Campus Services: John Lewis Student Center & Post Office

Campus Services: Student Health Services (STAMP)

Student Life

Department in the College of Computing*

Administration

School of Computational Science and Engineering

School of Computer Science

School of Computing Instruction

School of Cybersecurity and Privacy

School of Interactive Computing

Department in the College of Engineering*

Department in the College of Lifetime Learning*

Administration

Center for 21st Century Universities (C21U)

Center for Education Integrating Science, Mathematics, and Computing (CEISMC)

Georgia Tech Professional Education

Department in the Ivan Allen College of Liberal Arts*

Work Location (Building)

Home Phone*

Phone

Work Phone

Phone

Work Email*

Work Schedule*

Please include days and hours.

Supervisor Information

Supervisor Full Name*

Supervisor Work Email*

Supervisor Work Phone Number*

Phone

Details for Reasonable Accomodation Request

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

Please describe the physical, mental, or cognitive impairment(s) that limit your ability to do your job.*

Describe the accommodations you are requesting. Please be as specific as possible.*

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

Describe how the requested accommodations will enable you to perform your job.*

Please provide any other information that might help the Georgia Institute of Technology evaluate your request.

Please attach ALL of the following documents:*

Medical Certification Form/Detailed Medical Statement
Voluntary Self-Identification Form

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

Drag and drop files here or

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.

Check this box and provide your electronic signature below if you agree with the statement above.*

Electronic Signature*

Send me a copy of my responses

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