Temporary Medical Condition Accommodation Request Form
Personal Information
Full Name
Email Address
Phone Number
Department/Unit
Job Title/Position
Medical Condition Details
Temporary Medical Condition (briefly describe)
Condition Onset Date
Expected Duration of Condition
Accommodation Request
Requested Accommodation(s)
Work Duties Impacted
Additional Information (if any)
Medical Provider Information (if applicable)
Provider's Name
Provider's Contact Information
Supporting Documentation Provided
Yes
No
Declaration
Signature
Date