Confirmation of Request for Reasonable Accommodation

The U.S. Equal Employment Opportunity Commission

EEOC Form 557
(see: Procedures for Providing Reasonable Accommodation for Individuals with Disabilities)

CONFIRMATION OF REQUEST FOR REASONABLE ACCOMMODATION
1. _____________________________________ Applicant's or Employee's Name Today's Date ____________________ Date of Request ___________________	________________________________________________ Applicant's or Employee's Telephone No. ______________________________________ Employee's Office
2. ACCOMMODATION REQUESTED. (Be as specific as possible, e.g., adaptive equipment, reader, interpreter)
3. REASON FOR REQUEST. If accommodation is time sensitive, please explain: Return Form to Disability Program Manager
(Disability Program Manager will assign number) 4. Log No.: ________________________________

CONFIRMATION OF REQUEST FOR REASONABLE ACCOMMODATION

_____________________________________
Applicant's or Employee's Name

Today's Date ____________________

Date of Request ___________________

________________________________________________
Applicant's or Employee's Telephone No.

______________________________________
Employee's Office

2. ACCOMMODATION REQUESTED. (Be as specific as possible, e.g., adaptive equipment, reader, interpreter)

3. REASON FOR REQUEST.

If accommodation is time sensitive, please explain:

Return Form to Disability Program Manager

(Disability Program Manager will assign number)

4. Log No.: ________________________________

EEOC Form 557 (Revised 2/01) PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE AND MUST NOT BE USED

This page was last modified on February 9, 2001.