Initial application may be made to the supervisor or the Office of Affirmative Action (406 Allen Administration Building).  All information received by agency personnel pertaining to your request for reasonable accommodation is kept confidential.  All medical information is maintained separately from personnel records.

To be completed by employee and returned to supervisor or Affirmative Action Office.
 
 

Name	Title	Salary Grade
Division	Work Location	Telephone

 
 

I am requesting the following reasonable accommodation(s):  __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

It is necessary for me to have this accommodation for the following reason(s):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Medical Documentation: Please inform your doctor of your application for an accommodation. Have your doctor send us medical documentation, including a brief statement of diagnosis and the limitations placed on your life functions and activities.  Information should be sent within thirty days to SUNY Brockport, 406 Allen Administration Building, Brockport, NY 14420-2929.
 
 

__________________________________    ______________________
Employee Signature                                              Date