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2. Accommodation Request*
   What specific accommodation(s) are you requesting?
4. 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.
5. Option

   1. Yes
   2. No
7. Time Frame*
   Is your accommodation request time sensitive? If yes, explain.
8. Option

   1. Yes
   2. No
10. Job Functions
    What, if any, essential job functions are you having difficulty performing?
12. Employment facilities and program
    What, if any, employment facilities and program are you having difficulty accessing?
14. Limitation of access to facility or program
16. 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?
17. Option

    1. Yes
    2. No
19. 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.
21. Name
22. Date
24. Upload
    Additional attachments can be made to this form.
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

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