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Accommodation Request On-line Form for Employees

  1. What specific accommodation(s) are you requesting?

  2. If you are not sure what accommodation(s) is needed, do you have any suggestions about what options we can explore? If yes, explain.

  3. Is your accommodation request time sensitive? If yes, explain.

  4. What, if any, essential job functions are you having difficulty performing?

  5. What, if any, employment facilities and program are you having difficulty accessing?

  6. Have you previously been accommodated during your employment with Contra Costa County? If yes, what were they and how effective were they?

  7. 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.

  8. Additional attachments can be made to this form.

  9. Leave This Blank:

  10. This field is not part of the form submission.