Employee request for work accommodation

Instructions

Complete the form in full and hit submit. Your request will then be electronically submitted to your supervisor.

Contact the HR leave and accommodation management office at 612-348-4082 if:

  • You need assistance completing this form
  • You would like to discuss your request prior to submitting to your supervisor
  • Your supervisor has not contacted you within 1 week of submitting your request
Employee information
*
Required 9 digits
*
*
*
*
*
*
*
*
Type of accommodation being requested
Maximum 130 characters
*
Is this a permanent accommodation?

*
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
Type of accommodation being requested






Choose all that apply.
*
Maximum 130 characters
Is the accommodation medically necessary?

*
Have you received an accommodation in the past for this same limitation?

*
Maximum 130 characters
Explanation for request
Max 150 characters
*
Max 150 characters
*
Max 150 characters
*
Signature

By typing my name below, I authorize my supervisor to share this information with my manager and the LAM Office.

Type your full name here.
*
mm/dd/yyyy
*
Top