Accommodation Request Intake Form

I. Personal Information: 

If Employee:


II. Relationship to NAU (please select all that apply): 

 


If member of public or applicant:

What barrier or problem are you experiencing with accessibility:

What remedy or accommodation are you requesting:

 

If Employee:

III. Please describe your limitations for which you are making this accommodation request: 

IV. What do you think might help you perform the essential functions of this job? 

V. Have you previously received an accommodation? What type? 


VI. Who is your preferred health care provider for documenting your impairment? 


VII. Will you sign an authorization so we are able to contact this doctor for purposes of helping us determine your eligibility under the ADA/ADAAA? 

           

VIII. Does your supervisor know of your impairment, accommodation request and/or that you are coming here for consultation? 

           

IX. We will need a current job description to review and give to your doctor to help determine impairments/accommodations. May we contact your department to get a current job description for your accommodation request? 

           

By submitting this form, you acknowledge that it will be submitted to the Northern Arizona University Disability Resources office (DR) for the purpose of beginning the interactive process to determine your eligibility for reasonable accommodation. Questions about this form should be directed to Todd Steen in the DR office at (928) 523-1775 or EmployeeAccommodations@nau.edu. Please also contact Todd Steen if you have not been contacted within 72 hours of submission.