University of Miami, Workplace Equity and Performance
Accommodation Request Form

The supervisor/department head must have an interactive meeting with the employee to discuss the request for a reasonable accommodation. The supervisor/department head must submit this form after meeting with the employee.

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 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 (*).

* Employee Name (You must type in a response)
  Name of the employee the accommodation request is for.
* Employee UMID: (You must type in a response)
Job Title (Type in a response)
  Job title of employee.
Department Name (Type in a response)
* Select Campus (Select only one)
* Supervisor Email Address (You must enter a valid email address)
Address (Type in a response)
* Work Phone # (You must type in a response)
* Supervisor/Department Head Completing Form: (You must type in a response)
* Select Employment Status: (Select only one)
* Select Disability (Select only one)
* Describe the type of accommodation being requested. (You must type in a response)
* Enter duration period. Help (You must type in a response)
  Enter the calander date you would like the accommodation to begin and end.
* Enter End Date (You must type in a response)
Attach a File(s) (Select a file to attach)
  Include supporting documentation, i.e., a letter from a health care provider explaining the employee's limitations, employee's job description, etc.
(Select a file to attach)
(Select a file to attach)

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.