HLS Reasonable Accommodation Request Form

The purpose of this form is to initiate the reasonable accommodation interactive process and assist Harvard Law School 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 Resources) and will be treated confidentially, with information shared only on a strict need-to-know basis.

Department/Unit*

Employee Name*

First Name

Last Name

Business Title*

Preferred email address*

Preferred telephone number*

Location (Building/Office #)

Manager/Supervisor*

First Name

Last Name

Manager/Supervisor email address*

HR Business Partner*

Dalila Santos Rachel Gallagher Lauren George Stacey Emerton (HR Only)

Please describe the accommodation you are requesting in explicit detail.*

File Upload

Please upload any supporting documentation regarding your accommodation request. Please note, this documentation will remain confidential and only be used internally within Human Resources to determine our ability to consider your accommodation request in line with business needs of your department.

It is possible that we may need to request additional documentation for review.

File

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File uploads may not work on some mobile devices.

Employee Signature

I give Harvard Law School permission to explore possible eligibility and reasonable accommodations under the Americans with Disabilities Act and the ADA Amendments Act (any applicable related laws). I understand that I am responsible for providing medical documentation from my health care provider(s) which substantiates my functional limitations and expected duration as related to performing the essential duties of my job. I further understand that I may be required to complete and sign a release of information giving University Disability Services and/or Harvard Law School Human Resources permission to consult with my health care professional(s) as necessary in order to determine that I am a employee with a disability, to seek clarification regarding any functional limitations resulting from my condition(s), and to assist in the exploration of possible reasonable accommodations.

Signature*

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Date*