Office of Diversity, Equity & Inclusion

Binghamton University

Office of Diversity, Equity & Inclusion

LSG 663

P.O. Box 6000

Binghamton,N. Y.13902

Request for Reasonable Accommodation

InitialApplication is to be submitted to your supervisor.

Yoursupervisor must complete Section C and thenreturn request to the Office of Diversity, Equity & Inclusion.Allinformation receivedby agency personnel pertaining to your request for a reasonable accommodation is kept confidential. This information is maintained separate from personnel records.

SectionA

PersonalInformation

(Tobe completed by applicant.)

Name: Title: Salary Grade: Department: Work Location: Telephone (Work): (Home): (Cell):

SectionB

Applicationfor Reasonable Accommodation

(Tobe completed by Applicant and submitted to Supervisor.)

Iamrequesting the followingreasonable accommodation(s):

_

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_------

Itis necessary for me to have this accommodation for the following reason(s):

_------

Ihave medical documentation to support this request. YesNo

Signature: Date:

Binghamton UniversityisanEqualOpportunityEmployer.

SectionC

Supervisor’sResponse to Request for Reasonable Accommodation

(Tobe completed by Supervisor and mailed toOffice of Diversity, Equity & Inclusion within 7 working days of receipt.)

I have received your application for an accommodation.

Approved

Comments

Nodecision has been made at this time. We will continue to assess your request. The Office of Diversity, Equity & Inclusionwill contact you.

Comments:

Supervisor Name (Print) Telephone (Work)

Signature: Date:

(Supervisor)

SectionD

Notificationof Need forAdditionalInformation

(Tobe completed by the Office of Diversity, Equity & Inclusion and returned to Applicant.)

TheOffice of Diversity, Equity & Inclusion has received your application for a reasonable accommodation. We are continuing to assess your request.

We require no additional information fromyou at this time.

Thereview process will include an evaluation of all relevant information. This may include an interview with you and/or your supervisor. Aftercompletion 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.

Tomake a determination, we need the following information:

Medical Documentation

Pleaseinform 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

SectionE

NotificationthatBinghamton UniversitywillprovideReasonableAccommodation

(Tobe completed by the Office of Diversity, Equity & Inclusion and returned to Applicant.)

Weare 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 accommodationthat you requested on . Please discuss this with your supervisor.

Ifyou have any questions, pleasecall the office at (607) 777-4775.

Signature: Date:

(Chief Diversity Officer,Office of Diversity, Equity & Inclusion)

SectionF

Notificationof Denial for Accommodation

(Tobe completed by the Office of Diversity, Equity & Inclusion and returned to Applicant.)

Applicant Name: Title:

Department: WorkLocation:

Binghamton University regrets to informyou that your request for an accommodation dated has been denied.

Yourrequest was denied for the following reason(s):

______

______

______

______

Signature: Date:

(Chief Diversity Officer,Office of Diversity, Equity & Inclusion)

Denial of Request Options

Youhave a number of options if your Request for a Reasonable Accommodation isdenied by the University.

•Youmay choose to accept the University’sdecision and end the process at this point.

•Youmay file a Charge of Discrimination underthe Americans with Disabilities Act with:

othe Equal Employment OpportunityCommission (EEOC) within 300 days of denial of the request by this Department;

oor with the State Division ofHuman Rights under the StateHuman Rights Law and/or the

Americans with Disabilities Act within one yearof the denial;

•Or you may initiate a private right of action in NYS Supreme Court within three yearsof the denial. Any one of the steps may be initiated at any point after the first agency denial.