eFMLA, Inc.

ADA Compliance Solutions

Form DI-6512

Reasonable Accommodation Request - Information Tracking

⚠️ Contains PHI

Requestor Info

Job Info

Accommodation

Review

Requestor Information

First Name *

Last Name *

Office/Bureau *

Date Request Received *

Receiver Information (Who received the request)

Receiver First Name *

Receiver Last Name *

Receiver Telephone

Receiver Email

Job Information

Position Title Held

Occupational Series

Grade Level

Office Location

Accommodation Information

Accommodation Type *

12A - Job Application Process

12B - Essential Job Functions

12C - Equal Benefits of Employment

Accommodation Requested

Disability Type

Permanent Disability

Temporary Disability/Limitation

Cancel