Human Resources

Applicant/Employee Accommodation Request

CONFIDENTIAL

*This form is to be used in conjunction with CWU Policy 2-35-040 and CWU Procedure 3-45-020*

This form will be used for documentation purposes only, confirming the request for an applicant/employee’s request for reasonable accommodation(s), and should be filled out either by the applicant/employee, or a family member, health care professional, or other representative acting on the individual’s behalf.

Employee Accommodation Request

Please request any accommodations using this form.

Field is required
Field is required
Field is required
Field is required
(###)###-####
Field is required, and needs to be a valid email address.
email@cwu.edu
Field is required
mm/dd/yyyy
Field is required
Field is required
(Be as specific as possible, e.g. adaptive equipment, reader, interpreter.)
Field is required
(If accommodation is time sensitive, please explain.)
IF DIFFERENT FROM APPLICANT/EMPLOYEE
mm/dd/yyyy

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