| Form A |
| Part I: Notification of need for accommodation |
| Name: |
| Contact details: |
| Details if a current employee: |
| Position number: | Classification: |
| Branch or Division: |
| Describe request or need to be addressed: |
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| Professional assessment being requested | Yes / No |
| Date of request: |
| Name of person completing form: |
| Signature of person completing form: |
| Signature of person requesting accommodation: |
| If appropriate please attach supporting documentation. |
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| Part II: Clarification of need |
| Describe action taken to clarify both the need and the potential accommodations including advice sought from experts: |
Name of person completing form: |
| Signature of person completing form: |
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| Part III: Report on outcome of accommodation request |
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1. Was accommodation provided?
(If no, go to question 7) | Yes / No |
| 2. If yes, describe the accommodation provided: |
| 3. What was the dollar cost (if any) of this accommodation? $ | $ |
| 4. Is this accommodation usable only by the individual staff member? (e.g. a specific computer screen, approval of particular leave, etc)? | Yes / No |
| 5. Was this the accommodation requested by the employee? | Yes / No |
6. Date accommodation implemented:
(Go to question 9) | / / |
| 7. If the answer to Question 1 was no, please provide the reasons that the accommodation was not provided: (please attach relevant additional material) |
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| 8. Who authorised the decision not to provide accommodation? |
| 9. Has the employee been advised of the outcome of the request? | Yes / No |
| 10. Has the employee been advised of his/her appeal and complaint rights? | Yes / No |
| 11. Date the employee was advised: | / / |
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| Name of person completing form: |
| Signature of person completing form: |
| Date of completion: |
