Please submit this online form to Workplace Equity and Performance. Alternatively, you may type or print information and return it via fax to (305) 284-6214, (305) 243-6521 or by email firstname.lastname@example.org. Information contained on this form is confidential to the extent permitted by law. The accommodation request will be processed only when the requested medical documentation has been received by Workplace Equity and Performance. Please print or type your responses below, and submit additional information as necessary.
Please review our privacy statement relating to information we collect, choice/opt-out, and correction/updating of personal information before proceeding.
Required questions are marked with an (*).
Your form has been submitted. Someone from Workplace Equity and Performance will be contacting you. If you have any questions please contact our office at the Coral Gables campus (305) 284-3064 or the Miller School of Medicine (305) 243-7203.