Employee Disability Accommodation Request

This form is considered confidential and is maintained separately from the employee’s personnel records. For questions, please email or call 410-704-2162

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My Request is for a










Medical documentation from a treating medical provider may be required. The documentation must indicate the anticipated duration of the need for accommodation/modification, the medical restrictions the  condition presents, and any suggested accommodations/modifications. Additional documentation may be requested as part of the interactive process.