University of Pittsburgh Disability Resources and Services

Employee Accommodation Application

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Employee Accommodation Application

Introduction

Type: Employee Accommodation Application.

Please notify Disability Resources and Services (DRS) at (412) 648-7890 if you require assistance completing this form. All information obtained by DRS will be maintained in accordance with applicable confidentiality standards.

Please Note: Application will time out after an extended period of inactivity. It is best to complete the application in one sitting. You will receive a confirmation email once the application has been submitted.

Application Information

Start Termrequired field:

Contact Information

Email Addressrequired field:

Primary Phone Numberrequired field:Specify country code for Primary Phone NumberSpecify Primary Phone Number

Secondary Phone Number:Specify country code for Secondary Phone NumberSpecify Secondary Phone Number

Position

Job Titlerequired field:

Hiring Daterequired field:

Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2025).

Supervisor Information

Supervisor Full Namerequired field:

Supervisor Office Locationrequired field:

Supervisor Phone Numberrequired field:Country CodeSpecify Supervisor Phone Number

Supervisor Email Addressrequired field:

Permanent Address

Addressrequired field:

Cityrequired field:

State/Provincerequired field:

Zip Code/Postal Coderequired field:

List of Questions

Question 1: Employee Typerequired field

Faculty

Staff

Temporary

Post Doctoral

Regional Campus Affiliate

Question 2: Please state the nature of your disability/medical condition for which you are requesting accommodation(s).required field

Question 5: Is your condition temporary or permanent?required field

Temporary

Permanent

Question 6: How long have you been diagnosed with this condition?required field

Question 7: Please provide a brief description of your job responsibilities.required field

Question 8: Please explain the aspects of your job responsibilities that are impacted by your condition and how/to what extent they are impacted.required field

Question 9: Please list the reasonable accommodation(s) you are requesting.required field

Question 10: Explain how the requested accommodation will enable you to perform the essential functions of your job.required field

Question 11: How long do you anticipate the need for an accommodation?required field

Question 12: Is there any other information you would like to provide?

Form Submission

Questions?

Disability Resources and Services
140 William Pitt Union
3959 Fifth Ave.
Pittsburgh, PA 15260
Phone: 412-648-7890
Fax: 412-624-3346
Monday - Friday: 8:30 a.m. to 5 p.m.
Email: drsrecep@pitt.edu