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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.

APPLICANT/EMPLOYEE INFORMATION
(Be as specific as possible, e.g. adaptive equipment, reader, interpreter.)
(If accommodation is time sensitive, please explain.)
IF DIFFERENT FROM APPLICANT/EMPLOYEE

For more information, please contact Human Resources, (509) 963-1202.

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