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Workplace Accommodation Request

* indicates a required field

Employee Information

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First NameRequired *

Last NameRequired *

Middle Name

Are you currently employed by CT State Community College, CSCU system office or Charter Oak State College?Required *

Are you currently employed by CT State Community College, CSCU system office or Charter Oak State College? Yes Are you currently employed by CT State Community College, CSCU system office or Charter Oak State College? No

Banner IDRequired *

Do not include @ sign. Please enter your 8-digit Banner ID number (e.g. 12345678). This is also known as your NetID.

EmailRequired *

Please use your college issued email address (e.g. @commnet.edu OR @ctstate.edu).

Phone Number

Job Title/Classification

Supervisor's Name

Department/Unit

Specific Accommodation Information

Please select the reason that best applies to why you're requesting a workplace accommodation(s).Required *

If Other selected, please explain.Required *

My diagnosed disability falls into the following categoryRequired *

Accommodation(s) Requested

Please be as specific as possible.

What major life function(s) are affected or impacted by your medical condition?

Which element(s) of your job function(s) are impacted by your medical condition(s)?Required *

Do you have a pending and/or approved FMLA request?Required *

Do you have a pending and/or approved FMLA request? Yes Do you have a pending and/or approved FMLA request? No

Does your position include in-person meetings/engagement/office coverage?Required *

Does your position include in-person meetings/engagement/office coverage? Yes Does your position include in-person meetings/engagement/office coverage? No

If Yes, please describe in-person interactions in detail.Required *

The duration of my accommodation request is - Required *

The duration of my accommodation request is - Permanent The duration of my accommodation request is - Temporary The duration of my accommodation request is - Unknown

Medical Verification of Impairment from physician/health care providerRequired *

Check the appropriate box

I am attaching documentation to this request The disability and the need for reasonable accommodation is obvious; no medical documentation needed Medical verification needs to be obtained from medical provider

Upload supporting document(s)

Acknowledgement StatementRequired *

I give the Connecticut State Colleges and Universities System Office permission to explore coverage and reasonable accommodations under the Americans with Disabilities Act of 1990, and all applicable State and Federal laws. I understand that all information obtained during this process will be maintained and used in accordance with the ADA, including its confidentiality requirements.

I agree

Document Information

Document Title

FileRequired *

Maximum file size: 10240kb

Description