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DHR Form EO 016A <br />Reasonable Accommodation Work Sheet <br />Date of Review: <br />Review By: <br />Date of Accommodations) Request: <br />Accommodations) Requested for (Name): <br />Work Schedule: <br />Supervisor/Manager: <br />Position: <br />Department: <br />Work Location: <br />(July 2018) <br />CONFIDENTIAL <br />1. Does the individual requesting the accommodations) have a physical or mental <br />impairment that substantially limits a major life activity? <br />If yes, answer #2 below. <br />2. What mental or physical limitations is the individual experiencing either described by <br />the healthcare provider or the individual? (Attach additional pages if needed.) <br />3. List the essential duties of the position, and attach position description with essential <br />duties highlighted: <br />