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Employee Disability Accommodation Request Form

Please complete the following form as completely as necessary to document your request. Note that documentation from a medical professional may be required. Form should be submitted the appropriate Human Resources Office:  
 
SBU West Campus, RF & HSC Employees - Human Resource Services (Attn: Paulene Toussaint)
Phone: (631) 632-6161 / Fax: (631) 632-6208 / Email: hrs_benefits@stonybrook.edu
Stony Brook Medicine Employees - SBM Human Resources (Attn: Tami Goldberg)
Phone: (631) 444-4734 / Fax: (631) 444-4724 / Email: tami.goldberg@stonybrook.edu
LISVH Employees - LISVH Human Resources (Attn: Denise Muscarella)
Phone: (631) 444-8617 / Fax: (631) 444-8517 / Email: lisvhhr@stonybrook.edu

Your Information


 


Impairment Information

Please note that documentation from a medical provider(s) may be necessary



Accommodation Information

NOTE: Attach additional sheets if necessary


Certification


 

Print as PDF.
After printing, please submit the form to the appropriate HR office.

 

 
   
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