Reasonable Accommodation Request Form
The purpose of this form is to initiate the reasonable accommodation interactive process and assist Harvard University in determining whether, or to what extent, a reasonable accommodation is necessary for an employee with a disability to perform one or more essential functions of his or her job safely and effectively. This form is to be completed and will reside with your accommodation coordinator (Human Resources or University Disability Services) and will be treated confidentially, with information shared only on a strict need-to-know basis.

University Disability Services
Employee Name *
Your answer
Affiliation/School *
Your answer
Department/Unit *
Your answer
Job title
Your answer
Preferred telephone number *
Your answer
Preferred email *
Your answer
Work address
Your answer
Manager/Supervisor
Your answer
Manager/Supervisor's telephone
Your answer
Other Departmental Administrator (if applicable)
Your answer
Human Resources Representative
Your answer
Human Resources Representative's telephone
Your answer
The accommodation requested is: *
Your answer
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