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    Accommendation Request Forms

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    Virginia Dare Behavioral Health Services
    An employee of Virginia Dare Behavioral Health Services has submitted an accommodation request form to their employer. The form requests a specific accommodation and indicates whether the accommodation is permanent or temporary. It also states that the accommodation will allow the employee to perform the essential functions of their job. The employee's healthcare provider may provide additional documentation to certify the need for the requested accommodation.

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    Accommendation Request Forms

    Uploaded by

    Virginia Dare Behavioral Health Services
    52 views1 page
    An employee of Virginia Dare Behavioral Health Services has submitted an accommodation request form to their employer. The form requests a specific accommodation and indicates whether the accommodation is permanent or temporary. It also states that the accommodation will allow the employee to perform the essential functions of their job. The employee's healthcare provider may provide additional documentation to certify the need for the requested accommodation.

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    An employee of Virginia Dare Behavioral Health Services has submitted an accommodation request form to their employer. The form requests a specific accommodation and indicates whether the accommodation is permanent or temporary. It also states that the accommodation will allow the employee to perform the essential functions of their job. The employee's healthcare provider may provide additional documentation to certify the need for the requested accommodation.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    52 views1 page

    Accommendation Request Forms

    Uploaded by

    Virginia Dare Behavioral Health Services
    An employee of Virginia Dare Behavioral Health Services has submitted an accommodation request form to their employer. The form requests a specific accommodation and indicates whether the accommodation is permanent or temporary. It also states that the accommodation will allow the employee to perform the essential functions of their job. The employee's healthcare provider may provide additional documentation to certify the need for the requested accommodation.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    Virginia Dare Behavioral Health Services, Inc.

    “A Community Healthcare Provider”


    Accommodations

    Request for Accommodations/Removal of Barriers

    Accommodation Request Form

    __________________________________ _________________________
    Employee Name Date

    __________________________________
    Department

    __________________________________
    Job Title

    I am requesting the following accommodation: ___________________________________________

    _____________________________________________________________________________________

    I request that this accommodation be: Circle One – Permanent or Temporary

    This will permit me to perform the essential functions of my job.

    The attached documentation provided by my health care provider (if necessary) certifies the need
    for the requested accommodation.

    _____________________________
    Employee Signature

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