Employee Disability Accommodation Request

This form is considered confidential and is maintained separately from the employee’s personnel records. For questions, please email adarequest AT_TOWSON or call 410-704-2162

Section

Employee Name

Employee ID

Title

Campus Address

Campus Phone

Supervisor

Supervisor Phone

My Request is for a

Permanent or Long Term Disability

Permanent or Long-Term Disability (greater than 6 months)

Duration:

Short Term Disability

Short Term Disability (less than 6 months)

Duration:

One Time Event or Special Program

Event:

Date:

Location:

Please describe in detail how your disability affects your ability to perform your work duties:

Requested or recommended accommodation sought:

Medical documentation from a treating medical provider will be required. Please have your medical provider complete the ADA Medical Certification Form. The documentation must indicate the anticipated duration of the need for accommodation, the medical restrictions the condition presents, and any suggested accommodations. Additional documentation may be requested as part of the interactive process.