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 Office of Equity and Access (OEA)

SBU West Campus, RF & HSC, Stony Brook Medicine, and LISVH Employees- ADA Specialist (Attn: Natalie Mertens)

Phone: (631) 632-6280 / Fax: (631) 632-9428 / Email: oea_ada@stonybrook.edu

Your Information

Name

SBU ID#

Title

Department

Location

Supervisor

Address

Street Address

Address2

City

State/Province/Region

Postal/ZipCode

Country

Home or Cell Phone Number

Work Phone Number

Email Address

Impairment Information

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

What, if any, job function do you have trouble performing?

What, if any, employment benefit do you have difficulty accessing?

What limitation is interfering with your ability to perform your job or access an employment benefit?

Have you had any accommodations in the past for this same limitation? If yes, what were and how effective were they?

If you are requesting specific accommodation, how will that accommodation assist you?

Accommodation Information

NOTE: Attach additional sheets if necessary

Please indicate the specific accommodation requested.

If you are not sure what accommodation might be needed, do you have any suggestions or options?

Please indicate anticipated duration of the accommodation.

If your request is time sensitive, please indicate here.

Other

Certification

By submitting and/or printing this form, I am certifying the above statements to be true and factual to the best of my knowledge.

If you like a copy of this form, please provide your email.