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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:
Stony Brook Medicine Employees - SBM Human Resources (Attn: Tami Goldberg)
Phone: (631) 444-4734 / Fax: (631) 444-4724 / Email:
LISVH Employees - LISVH Human Resources (Attn: Denise Muscarella)
Phone: (631) 444-8617 / Fax: (631) 444-8517 / Email:

Your Information


Impairment Information

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

Accommodation Information

NOTE: Attach additional sheets if necessary




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