Reasonable Accommodation Request

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Requestor's Information

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1. Please identify the impairment(s) for which you are requesting reasonable accommodation and the expected duration of the impairment(s).(Required) This field is required.

2. Please describe how each impairment listed above affects your ability to perform a major life activity, and identify which major life activity(s) is/are most significantly affected. Examples of major life activities are: seeing, hearing, walking, breathing, smelling, caring for yourself, thinking, concentrating and working.(Required) This field is required.

3. Please answer the following based on your status. EMPLOYEES: Describe how your impairment limits your ability to perform the essential functions of your position. Please identify each of the functions of your position affected and specify how your impairment limits your ability to perform each function. APPLICANTS: Describe how your impairment limits your ability to perform the essential functions of your position. Please identify each of the functions of your position affected and specify how your impairment limits your ability to perform each function. ALL OTHERS: Describe how your impairment limits your ability to participate in BSU’s programs, services or activities. Please identify each program, service or activity for which you are seeking accommodation.(Required) This field is required.

4. Describe the accommodation(s) you are requesting.(Required) This field is required.

5. Please answer the following based on your status. EMPLOYEES: Explain how the requested accommodations will enable you to perform the essential functions of your job. Please be specific. APPLICANTS: Explain how the requested accommodation(s) will allow you to participate in the application and/or selection process. ALL OTHERS: Explain how the requested accommodations will enable you to participate in each program, service or activity. Please be specific.(Required) This field is required.

6. Please answer the following based on your status. EMPLOYEES: Do you need assistance to identify reasonable accommodations that may enable you to perform the essential functions of your position? If so, please indicate what type of assistance you need. APPLICANTS: Do you need assistance to identify reasonable accommodations that may enable you to complete the application and/or selection process? If so, please indicate what type of assistance you need. ALL OTHERS: Do you need assistance to identify reasonable accommodations that may enable you to participate in BSU’s programs, services? If so, please indicate what type of assistance you need.(Required) This field is required.

7. Please answer the following if you are an EMPLOYEE. All others, indicate N/A. If you receive the requested accommodations, will you be able to perform all of the functions of your position? If not, please describe the specific functions you believe you will not be able to perform.(Required) This field is required.

8. Please answer the following if you are an EMPLOYEE. All others, indicate N/A. Have you previously received any accommodation(s)? If so, please list them and the dates of each.(Required) This field is required.

9. Mark the appropriate selection regarding medical documentation.(Required)

I have enclosed medical documentation (below) of my impairment with this request. I have already provided medical documentation relating to my impairment(s). I will submit my medical documentation separately to the OEO. My impairment is open and obvious and does not require medical documentation.

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Supporting Medical Documentation

Medical Verification of Impairment. All medical documentation should be recent and should describe: the impairment; the nature, severity, and duration of the impairment; the activity(s) that the impairment limits; and the extent to which the impairment limits the individual’s ability to perform the activity or participate in the activities. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Supporting Medical Documentation

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