EOA - Reasonable Accommodation Request Form

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In keeping with local, state and federal laws, Vanderbilt provides reasonable accommodations to qualified employees with disabilities. In general, it is the employee’s responsibility to inform his/her supervisor that he/she needs a disability related accommodation in order to perform the essential functions of the job. A supervisor is not required to provide reasonable accommodations if he/she is not aware of the employee’s need and desire for the accommodation. Reasonable accommodations are determined, identified and implemented in a collaborative process among the employee, supervisor and Equal Opportunity and Access (EOA).

Contents of this request are confidential and will only be shared as needed with the appropriate personnel to consider the implementation of a reasonable accommodation. This form will not be placed in your employment record file. All medical documentation will be kept confidential. To help initiate your request, complete both forms and forward your supporting medical documentation to:

Equal Opportunity and Access (EOA)
Loews, Suite 780
2100 West End Avenue
Nashville, TN 37203
or fax to (615) 343-4709
Today's Date: Today's Date: / MM / DD YYYY
Employee ID #:
Name: Name: First Last
Job Title/ Dept:
Immediate Supervisor:
Supervisor’s phone #:
Employee Relations Representative:

(Please note that while your supervisor will be involved in the process, information about your medical condition, including medical documentation, will not be shared,
unless authorized by you.)
Home Address: Home Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email:
Work Phone:
Home Phone: