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Job Accommodation

First Name: *

Last Name: *

Employee ID Number: *

Official EKU email: *

Phone: *

Best way for the HR Office to reach you.

What accommodations are you requesting?: *

If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore? :

yes

no

If yes, please explain.:

Is your accommodation request time sensitive?:

yes

no

If yes, explain.:

What, if any, job function(s) are you having difficulty performing?:

What, if any, employment benefit are you having difficulty accessing?:

What limitation is interfering with your ability to perform your job or access an employment benefit?:

Have you had any accommodations in the past for this same limitation? :

yes

no

If yes, what were they and how effective were they?:

If you are requesting a specific accommodation, how will that accommodation assist you? :

Please provide any additional information that might be useful in processing you accommodation request.:

Leave this field blank:

BluMine Health Clinic offers medical services to all employees covered by EKU health insurance,...