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:
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.
_________________________________________________________ ____________________
Signature
of Faculty/Staff Member Date
_________________________________________________________ ____________________
Supervisor’s
Signature Date
_________________________________________________________ ____________________
Signature
of Dean/Director Date
_________________________________________________________ ____________________
Signature
of Workplace Accommodation Interactive Team Member Date
_________________________________________________________ ____________________
Signature
of Divisional Vice President Date