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DHR EO 013 <br />(Re -issued: July 2018) <br />CONFIDENTIAL <br />County of Hawaii <br />Employee Request for Reasonable Accommodation <br />Please complete this form and submit it to your supervisor to request a <br />reasonable accommodation to better access your workplace, perform <br />your job duties, or to enjoy a benefit of employment. <br />Name: Telephone No.: <br />Other contact information: <br />Job Title/Department/Location: <br />Accommodation Requested for: <br />(Please check all that apply and identify the specific element of your <br />employment for which you are requesting the accommodation) <br />❑ Access to workplace: What feature of your workplace is giving you <br />difficulty? <br />❑ Performance of job duties: What job duty (or duties) is giving you <br />difficulty? <br />❑ Benefit of employment: What benefit of employment is giving you <br />difficulty? <br />F Other (please specify) <br />