Reasonable Accommodation – MCON Management

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Instructions:

This form is intended for employees who need a reasonable accommodation due to a disability or medical condition. Please complete the form and submit it to Kimber in HR. All information provided will be kept confidential and used only to process your accommodation request.

Name

First

Last

Direct Supervisor

Date of Request

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Cell

Please describe the nature of your disability or medical condition that requires accommodation: (Optional: You may attach additional documentation from your healthcare provider if needed.)

How does this condition impact your ability to perform your job duties? (Please be as specific as possible.)

What specific accommodation(s) are you requesting? (Examples: modifications to work environment, adjustments to job duties, assistive devices, flexible work hours, etc.)

How will the requested accommodation(s) assist you in performing your job duties?

Have you received accommodations in the past for this or a similar condition? If yes, please describe the accommodations and their effectiveness:

Additional Information Please provide any additional information that may be helpful in processing your request:

Medical Documentation: If applicable, please attach any medical documentation that supports your request for accommodation. (Note: The company may require documentation from a healthcare provider to support your request.)

Click or drag files to this area to upload. You can upload up to 5 files.

Acknowledgment I understand that the information provided in this form will be used solely for the purpose of processing my accommodation request. I also understand that the company may need to engage in an interactive process with me to determine the appropriate accommodations.

Clear Signature

Date Signed