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Accommodation Request Online Form for Employees
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Accommodation Request
*
What specific accommodation(s) are you requesting?
Suggestions
If you are not sure what accommodation(s) is needed, do you have any suggestions about what options we can explore? If yes, explain.
Option
Yes
No
Time Frame
*
Is your accommodation request time sensitive? If yes, explain.
Option
Yes
No
Job Functions
What, if any, essential job functions are you having difficulty performing?
Employment facilities and program
What, if any, employment facilities and program are you having difficulty accessing?
Limitation of access to facility or program
Contra Costa County Accommodation
Have you previously been accommodated during your employment with Contra Costa County? If yes, what were they and how effective were they?
Option
Yes
No
Requirements
You may be required to provide medical documentation, if necessary, to process your accommodation request, If you are unable to provide the necessary documentation, the County may obtain it's own medical assessment.
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