Job Accommodation Request

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* Employee Name

* Employee Job Title

* Email Address

* Phone Number

* Team

* Country/State

* Manager Name

* Manager Phone Number

Part of the process to determine eligibility for employment accommodations under the ADA law requires you to submit medical information to us. Therefore, before we can make a determination as to whether a request for accommodation can be granted, we need to obtain more information about your condition. The following questions need to be completed if you choose to pursue a reasonable accommodation as defined by ADA

*Please list the challenges/problems you are facing in your current position due to your illness/injury

*Please list the accommodations you are requesting which you believe will allow you to perform the essential functions of your job

* Please list all supporting medical information you will be providing with submission of this request

* Required Field