TX

SECTION III. REASON FOR REQUEST

What, if any, job function 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?

SECTION IV. OTHER

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

I acknowledge that I may be required to submit medical documentation from my healthcare provider to support my request.
Signature:
Date:

Important Note:
Employers may mistakenly discontinue the interactive process when an employee requests an accommodation that is not effective, would be too difficult, or is not legally required. However, the