MATC REASONABLE ACCOMMODATION REQUEST FORM

APPLICANT ___    REGULAR EMPLOYEE ___

NAME: _______________________________________________DATE: _____________
ADDRESS: _______________________________________________________________
TELEPHONE: _____________________________________________________________
CAMPUS LOCATION OF PERSON SUBMITTING REQUEST: _________________________
NEED FOR ACCOMMODATION: _______________________________________________

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REQUESTOR'S SUGGESTED ACCOMMODATION: _________________________________

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DOCUMENTATION OF DISABILITY: (Please Attach)

MATC'S ACCOMMODATION PLAN: ____________________________________________

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SUPERVISOR APPROVAL (Circle one): APPROVED    DISAPPROVED

                PLEASE SIGN AND DATE ONE STATEMENT ONLY!!!

I concur with the proposed accommodation:
 DATE: ______________               ________________________________
                                    (Employee Signature)

I wish to appeal the committee's proposal:
 DATE: ______________               ________________________________
                                    (Employee Signature)

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                            FOR OFFICE USE ONLY

 REQUEST RECEIVED BY:      ___________________________________
                           ADA/504 coordinator or designee   Date

 ACCOMMODATION APPROVED:   ___________________________________
                           ADA/504 coordinator or designee   Date