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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, Stony Brook Medicine, and LISVH Employees ADA Specialist (Attn: Paulene Toussaint)
Phone: (631) 632-6280 / Fax: (631) 632-9428 / Email:  oide_ada@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