Binghamton University
Office of Diversity, Equity & Inclusion
LSG 663
P.O. Box 6000
Binghamton, N. Y. 13902
Request for Reasonable Accommodation
Initial Application is to be submitted to your supervisor.
Your supervisor must complete Section C and then return request to the Office of Diversity, Equity & Inclusion. All information received by agency personnel pertaining to your request for a reasonable accommodation is kept confidential. This information is maintained separate from personnel records.
Section A
Personal Information
(To be completed by applicant.)
Name: Title: Salary Grade: Department: Work Location: Telephone (Work): (Home): (Cell):
Section B
Application for Reasonable Accommodation
(To be completed by Applicant and submitted to Supervisor.)
I am requesting the following reasonable accommodation(s):
_
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It is necessary for me to have this accommodation for the following reason(s):
_------
I have medical documentation to support this request. Yes No
Signature: Date:
Binghamton University is an Equal Opportunity Employer.
Section C
Supervisor’s Response to Request for Reasonable Accommodation
(To be completed by Supervisor and mailed to Office of Diversity, Equity & Inclusion within 7 working days of receipt.)
I have received your application for an accommodation.
Approved
Comments
No decision has been made at this time. We will continue to assess your request. The Office of Diversity, Equity & Inclusion will contact you.
Comments:
Supervisor Name (Print) Telephone (Work)
Signature: Date:
(Supervisor)
Section D
Notification of Need for Additional Information
(To be completed by the Office of Diversity, Equity & Inclusion and returned to Applicant.)
The Office of Diversity, Equity & Inclusion has received your application for a reasonable accommodation. We are continuing to assess your request.
We require no additional information from you at this time.
The review process will include an evaluation of all relevant information. This may include an interview with you and/or your supervisor. After completion of the review, you will be informed in writing by the Office of Diversity, Equity & Inclusion regarding the decision. We anticipate that the decision will be made by (Date) . If you have any questions, please call the office at (607) 777-4775.
To make a determination, we need the following information:
Medical Documentation
Please inform your doctor of your application for an accommodation and have your doctor send us medical documentation, including the limitations placed on your life functions and activities. Information should be sent by (Date) to: Binghamton University, Office of Diversity, Equity & Inclusion, LSG 663, P.O. Box 6000, Binghamton, NY 13902. If you need more time, you must call the Office of Diversity, Equity & Inclusion at (607) 777-4775 to request an extension.
Other
Signature Date:
(Chief Diversity Officer, Office of Diversity, Equity & Inclusion)
2
Section E
Notification that Binghamton University will provide Reasonable Accommodation
(To be completed by the Office of Diversity, Equity & Inclusion and returned to Applicant.)
We are pleased to inform you that based on additional information and with the approval of your supervisor, Binghamton University is able to provide you the reasonable accommodation that you requested on . Please discuss this with your supervisor.
If you have any questions, please call the office at (607) 777-4775.
Signature: Date:
(Chief Diversity Officer, Office of Diversity, Equity & Inclusion)
Section F
Notification of Denial for Accommodation
(To be completed by the Office of Diversity, Equity & Inclusion and returned to Applicant.)
Applicant Name: Title:
Department: Work Location:
Binghamton University regrets to inform you that your request for an accommodation dated has been denied.
Your request was denied for the following reason(s):
______
______
______
______
Signature: Date:
(Chief Diversity Officer, Office of Diversity, Equity & Inclusion)
Denial of Request Options
You have a number of options if your Request for a Reasonable Accommodation is denied by the University.
• You may choose to accept the University’s decision and end the process at this point.
• You may file a Charge of Discrimination under the Americans with Disabilities Act with:
o the Equal Employment Opportunity Commission (EEOC) within 300 days of denial of the request by this Department;
o or with the State Division of Human Rights under the State Human Rights Law and/or the
Americans with Disabilities Act within one year of the denial;
• Or you may initiate a private right of action in NYS Supreme Court within three years of the denial. Any one of the steps may be initiated at any point after the first agency denial.