Reasonable Accommodation
GENESEE/ SHIAWASSEE COUNTY
REQUEST FOR REASONABLE ACCOMMODATION
Date: Organization: Name of Person Requesting Accommodation: Address: Phone or TTY number Other Contact:
I am requesting accommodation because (check one):
( ) I am applying for services and/ or employment and the accommodation will allow me to complete the application process:
( ) I am currently employed by _ and request a reasonable accommodation. My job title is __.
Describe the functional limitation(s) caused by your disability for which you are requesting the accommodation: Describe any accommodation(s) which you believe would assist you in (a) the application process, or (b) performing your job. If it is piece of equipment, include any available information about name of the device, brand, source, cost, etc: Describe how this accommodation will assist you: Describe any accommodation which you have used in the past for the same disability:
Official Use Only:
( ) Has already been provided ( ) Approved ( ) Denied
Reason for Denial: If the requested accommodation is denied because of undue hardship, an explanation of the undue hardship, signed by the EO Liaison and Executive of the service provider must be attached. If the service provider and equally effective reasonable accommodation, that accommodation is: Signature of EO Liaison: ___ Date:
Individuals experiencing problems in receiving a response to a request for reasonable accommodation, who disagree with the action(s) taken by the providing agency or think they may have been subjected to discrimination on the basis of disability should promptly notify:
Craig Coney
Career Alliance, Inc.
711 North Saginaw Suite 300
Flint, MI 48503
810-233-5974 Ext 110
810-233-8652 FAX
810-233-4242 TTY
cconey@careeralliance.org
