Reasonable Accom Proc Form Amended

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DHR EO 011 (Re -issued: July 2018) WeIZ119110"'Lli I Documentation of Reasonable Accommodation for Job Application Process Name of Requestor: Position applied for: Department: Type(s) of Accommodation Requested: Request for Accommodation Granted: Name of Decision Maker Note Specifics: Date: Signature of Decision Maker If the request for accommodation was denied, please check all that apply below: ❑ Accommodation Ineffective ❑ Accommodation Would Cause Undue Hardship ❑ Medical Documentation Not Provided ❑ Medical Documentation Inadequate ❑ Other (Please identify)