Boise State University Request for Reasonable Accommodation

Employee Information

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Alternate Phone

Email

Supervisor

Campus Extension

Position

What specific accommodation are you requesting?

If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore? If yes, please explain.

If yes, please explain.

Is your accommodation request time sensitive? If yes, please explain.

Time Sensitive If yes please explain

What, if any, job function are you having difficulty performing?

What, if any, employment benefit are you having difficulty accessing?

What limitation is interfering with your ability to perform your job or access an employment benefit?

Have you had accommodations in the past for this same limitation? If yes, what were they and how effective were they?

What were they and how effective were they?

If you are requesting a specific accommodation, how will that accommodation assist you?

Provider Name

First Last

Provider Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Provider Office Phone

Provider Office Fax

Your physician will receive a letter from us requesting information on your impairment/disability and suggestions for accommodations.

Please provide any additional information/ documentation that might be useful in processing your accommodation request

Signature

Date