Reasonable Accommodation Request Form

Your information

Your name

Your Purdue University ID Number

Your phone number

Your email address

Questions to clarify accommodation(s) requested and the reason for the request(s)

Please provide your supervisor's name, campus telephone number, and campus email address. This field is required.

If you are completing this form on behalf someone else, please provide your name and relationship to the person. This field is required.

Identify the physical and/or mental impairment(s) for which you are requesting accommodation(s) and the expected duration of the impairment(s). Include the date of diagnosis. This field is required.

Explain how the impairment(s) listed affect(s) your ability to perform the essential functions of your position. If you are a new employee, state the anticipated difficulties you foresee in completing your job duties. Be as specific as possible regarding the job duties you are having difficulty performing or believe you will have difficulty performing. Note: Essential functions are duties that are basic or fundamental to a position. This field is required.

What specific accommodation(s) are you requesting, and how will this accommodation(s) assist you? This field is required.

What, if any, employment privileges are you having difficulty accessing? Please explain. This field is required.

Provide any additional information that might be useful in processing your accommodation request(s). This field is required.

Your information

Questions to clarify accommodation(s) requested and the reason for the request(s)

Submission