Employee Accommodation Request
Current HutchCC employees who have a need for accommodation should 1) submit this request and 2) provide Human Resources with documentation from a medical professional. Human Resources will work with the employee and the employee's supervisor to implement reasonable accommodations.
Sign in to Google to save your progress. Learn more
Your Name *
Employee ID Number *
Department and Supervisor *
Describe the job duties or functions you are having difficulty performing. *
Do you have a physical or mental impairment that limits your ability to perform your job duties? If yes, please explain. *
What specific accommodation(s) are you requesting? *
How will the accommodation(s) assist you? *
Is your accommodation request time sensitive? If yes, please explain. *
Is there any additional information that might be useful in helping us process your accommodation request?
Please respond to the following statement:  I understand that I must submit a diagnostic statement from a qualified medical provider that identifies my impairment and suggested accommodation(s). Documentation should be submitted to Human Resources. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms