Department of Human Resources

Employment Accommodations for University Employees

Registration Form

Employee Name___________________________________________________

Employee SS #____________________________________________________

Work Telephone ________________________Home Telephone_____________

Employment Status___________________________Hours_________________

Position Title_____________________________________________________

Supervisor's Name_________________________________________________

Supervisor's Phone_________________________________________________

*Disability/Condition_______________________________________________

*Services/Accommodations Currently Requested

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*Accommodations Currently Implemented

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Date of Registration _____________________________________

Signature___________________________