Tennessee State University
REASONABLE ACCOMMODATION REQUEST FORM
Tennessee State University will provide, upon request, reasonable accommodation(s) to qualified employees or
applicants for employment with disabilities that do not pose an undue hardship on the University.
PLEASE TYPE OR COMPLETE IN INK
Date of Request
Name
Position Applied for (if applicable)
Department
Current Job Title (if applicable)
Department
Home Address/Phone Number
Campus Address/Phone Number/E-Mail
Describe your need for reasonable accommodation including how your ability to perform the essential functions
of your job are adversely impacted (attach supporting documentation). Use additional sheets if necessary.
Provide your recommendation for reasonable accommodation(s) and information about associated costs, if any
(attach supporting documentation). Use additional sheets if necessary.
Signature of Employee/Applicant
Revised: 07/15/2012
Date