eFMLA, Inc.

ADA Compliance Solutions

Form DI-6513

Reasonable Accommodation Request Confirmation

⚠️ Contains PHI

1

Applicant's or Employee's Information - Questions 1-6

First Name *

Last Name *

Telephone *

Email Address *

Today's Date *

Date of Request *

2

Reasonable Accommodation Information - Questions 7-9

7. What accommodation are you requesting? *

If you do not know what accommodation you need, describe the problem you are having.

8. Why do you need this accommodation? *

Explain how the accommodation will assist you in performing your job or participating in the application process.

9. Is your request time-sensitive? If yes, please explain.

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