Reasonable Accom Proc Form Amended

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DHR EO O16 (Re -issued: July 2018) CONFIDENTIAL Documentation of Reasonable Accommodation for Employee Name of Requestor: Position: Department: Type(s) of Accommodation Requested: Request for Accommodation Granted: Name of Decision Maker Date Note Specifics: Request for Accommodation Denied Because (check all that apply): ❑ Accommodation Ineffective ❑ Accommodation Would Cost Undue Hardship ❑ Medical Documentation Inadequate ❑ Accommodation Would Require Removal of an Essential Function ❑ Accommodation Would Require Lowering of Performance or Production Standard ❑ Other (please identify) Detailed reason(s) for the denial of accommodation (be specific, e.g., explain why the accommodation is ineffective and/or causes undue hardship, what production standard is reduced or lowered, what essential job function the accommodation would eliminate, etc.).