Employee Request for Accommodation Form

Reporting Party Information

Please provide your name and title here.

Enable additional features by logging in.

Your full name:

Your position/title:

Accommodation Request Type(Required):

This field is required.

Employee and Supervisor Information

Please provide your name and contact information, your supervisor's name and email, and the name and email of your department/unit's HR representative. (To find the name of your HR Representative, please review this website: https://hr.vcu.edu/about/contact/hr-contacts-for-schools-and-units/)

Name

Select Role

V# (if known)

Email address

Position/Title

Questions

Please describe which major life activity or major bodily function your chronic condition or disability impacts. (For example: caring for oneself, performing manual tasks, walking, seeing, hearing, sitting, speaking, breathing, learning, remembering, concentrating, immune system, respiratory system or cardiovascular system etc.).(Required) This field is required.

Describe how your condition or disability limits your ability to perform the essential functions of your job. Note: essential functions or duties are those that are the primary responsibilities of your position.(Required) This field is required.

Describe in detail the accommodation(s) you are requesting.(Required) This field is required.

Please add any additional information you think may be relevant to your request. This field is required.

Supporting Documentation (Note: Documentation Is Not Necessary In Order To Submit Form)

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Reporting Party Information

Employee and Supervisor Information

Questions

Supporting Documentation (Note: Documentation Is Not Necessary In Order To Submit Form)

Submission