Accommodation Request Form

In Accordance with CAFN Human Resources Manual 8.4 - Occupational Health and Safety

Title:

Department:

Date of Request

Describe request or need to be addressed:

Signature of person completing form

Signature of person requesting accommodation

If appropriate please attach supporting documentation.

Max. file size: 64 MB.

Clarification of Need:

Estimated cost of accommodation (if applicable):

Report of outcome of accommodation request (to be completed by HR Department)

Hidden

Describe the accommodation provided:

What was the dollar cost (if any) of this accommodation?:

Cost Centre/Expense coding

Date accommodation implemented

Hidden

Please provide the reasons that the accommodation was not provided: (please attach relevant additional material)

Please attach relevant additional material

Max. file size: 64 MB.

Who authorized the decision not to provide accommodation?

Hidden

Date the Employee was advised:

Signature

Date of completion: