University of Pittsburgh Disability Resources and Services

Employee Accommodation Application

You are here:

Home
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

By submitting this application, I am initiating the formal accommodation process and agree to be contacted by Disability Resources and Services to continue the interactive process.

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