Supervisor response form for work accommodation

Once you have determined if an accommodation request is accepted or denied, please complete the supervisor response form. A copy of your response will then be forwarded to the HR leave and accommodation management office and your employee.

To be completed by supervisor
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Reviewed with


Select all that apply
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Select final decision
Choose one


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If you are accepting the accommodation (summarize the accommodation)
mm/dd/yyyy
mm/dd/yyyy Please follow up with employee two weeks after implementation date.
If you are rejecting the accommodation (summarize other alternatives if applicable)

Select one

Signature
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mm/dd/yyyy
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