Virginia Dare Behavioral Health Services, Inc.

“A Community Healthcare Provider”

Accommodations

Request for Accommodations/Removal of Barriers

Accommodation Request Form

__________________________________ _________________________
Employee Name Date

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Department

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Job Title

I am requesting the following accommodation: ___________________________________________

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I request that this accommodation be: Circle One – Permanent or Temporary

This will permit me to perform the essential functions of my job.

The attached documentation provided by my health care provider (if necessary) certifies the need
for the requested accommodation.

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Employee Signature