Workplace Accommodation Agreement

 

The information provided below outlines the disability-related employment accommodations being provided for:

 

Employee:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††† ††††††††††††††† ID:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

 

Department:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††† Division:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† _______

 

The following accommodations are provided at no cost to the above Texas State employee based upon the disability-related needs of the employee as requested and approved by the Office of Disability Services in consultation with the Texas State Workplace Accommodation Interactive Team. These accommodations were determined based on the following documentation provided by the employee:

 

Type of documentation provided/Name of Specialist:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† _____________ ††††††††††††††††††††††††††

 

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Date(s) of documentation:†††††††††††††††† †††††††††††††††††††††††††††††††

Accommodations †††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††† Effective Dates††††††††††

1.††††† ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††††††††††††††††††††††††††† †††††††††† †††††††††††††††††††††††††††††††††††

2.††††† ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† †††††††††† †††††††††††††††††††††††††††††††††††

3.††††† ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††††††††††††††† ††††††††††† ††††††††††††††††††††††† ______††††††††

Last Date Accommodation will be Required (if applicable):††††††††††††††††††††††††††††††††††††††††††††††

As the employee requesting accommodations, I understand the accommodations outlined above which my supervisor has agreed to provide, are based on the documentation submitted for this request and supplemental documentation will be required if additional accommodations are necessary to meet my disability-related needs.

 

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Signature of Faculty/Staff Member††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††† Date

 

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Supervisorís Signature††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††† Date

 

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Signature of Dean/Director†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††† Date

 

_________________________________________________________††††††††††††††††† ____________________

Signature of Workplace Accommodation Interactive Team Member†††††††††††††††††††††† Date

 

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Signature of Divisional Vice President†††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††† Date††††††††††††††††††