Accommodation Request Form

The University of New Haven (the "University") is committed to complying with all laws which protect qualified individuals with disabilities. If you have a disability that requires an accommodation to perform the essential functions of the role, please complete this form for the University to appropriately engage in an interactive process regarding this request.

To be eligible for a reasonable accommodation under the Americans with Disabilities (ADA), you must be qualified to perform the essential functions of your position with or without an accommodation and have a qualifying disability that limits a major life function.

This form should be completed in its entirety for all accommodation requests. No personal medical information should be provided on this form. If medical information is required to assess this request, the individual will be required to contact the University's disability management company which is currently MedLeave Solutions. MedLeave Solutions, in conjunction with the medical professionals they utilize to assess claims, will only advise the University of the validity of the documentation provided attesting to the disability.

No internal University conversations regarding an individual's personal health information should ever occur.

1Employee Information > 2Accommodation Request Information > 3Supervisor / Dean Information > 4Review Your Entry
Employee Information
Employee Name Employee Name First Last
Employee Email
Employee Title
Employee Department
Employee Home Address Employee Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

Accommodation Request Form

Accommodation Request Form

Employee Information