Work accommodation request

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To request an accommodation:

1. Complete this form in full and click "Submit For Review". Your request will be automatically sent to your supervisor.

Required Fields are indicated by a red asterisk mark *

2. Contact the Leave and Accommodation Management (LAM) Office at 612-348-4082 or email HR.LAM.Office@hennepin.us if:

You need assistance while completing this form.
You would like the LAM Office to review this form prior to submitting.
Your supervisor has not contacted you within 1 week after submitting this form.

Are you a current county employee or an applicant that has received a conditional offer of employment?

Employee

Applicant

Will you be submitting for yourself or for an employee?

Myself

An employee

Enter your 9 digit Employee ID and press the Search key:

Enter the employee's 9 digit Employee ID and press the Search key:

Employee ID

Employee search result:

Is this the correct employee?

Yes

EmpFlag

Error message

First name

Last name

Employee ID

Job title

Department

Employee phone

Work email address

Personal email address

Please confirm your personal email address

Supervisor name

Do you want to add an alternate supervisor?

Yes

Click Yes to add an alternate supervisor, who will be notified of your work accommodation request. The supervisor that was automatically filled in is your supervisor as listed in Apex.

Alternate supervisor name

Click to change alternate supervisor

Alternate supervisor search

Case sensitive (e.g. upper case first letter). Please enter at minimum the first two letters of both first and last name and press Search

First name

Last name

First name	Last name	Email address	Department

First Name

Last Name

By checking this box, I am opting out from authorizing the release of my medical information. I understand that Hennepin County may request the authorization at a later time if it is needed for the decision process of my accommodation request.

RELEASE OF MEDICAL INFORMATION

I hereby authorize the release of information relating to my medical condition to the department and individual listed below for the purpose of assisting her/him in providing reasonable accommodation or other job adjustments in my employment at Hennepin County.

I hereby release Hennepin County (and all employees thereof) and any organization, company, or person furnishing information expressly authorized above, from any liability or damage which may result from providing the information requested.

Department & Individual released to:

Medical Provider information:

Clinic name

Provider name

Street address

Country

City

State

ZIP or Postal code

Phone

Fax

Clinic name

Provider name

Address

Country

City

State

ZIP or Postal code

Phone

Fax

Sign to authorize this release

By typing my name in the following box I am signing my name and agreeing to the terms and conditions stated above. I certify the information I have provided is correct to the best of my knowledge, and that this information will be used for the purpose of reviewing my request for a workplace accommodation. I understand that the medical information obtained during this process may be shared with others involved in the decision making process. I also understand that an incomplete or inaccurate form may affect the processing of my request.

Employee signature

Date

I am completing this form for someone else and by checking this box and typing my name in the signature line, I am signing my name and certifying the information I have provided above is correct to the best of my knowledge. I have reviewed this work accommodation request with the person requesting the accommodation and they understand that the medical information obtained during this process may be shared with others involved in the decision making process.

Employee signature

Date

Alt Sup First Name

Alt Sup MI

Alt Sup Last Name

Alternate Supervisor Phone

Alternate Supervisor Email

Alternate Supervisor User ID

Alternate Supervisor Title

Alternate Supervisor Dept

Sup First Name

Sup MI

Sup Last Name

Sup Email

Sup User ID

Sup Title

Sup Dept

Assign Sup First Name

Assign Sup Last Name

Assign Sup Name

Assigned Sup Phone

Assign Sup Email

Assigned Sup User ID

Assigned Sup Title

Assigned Sup Dept

Emp Dept ID

Emp User ID

Record ID

Emp Address Line 1

Emp Address Line 2

Emp Address City

Emp Address State

Emp Address Zip

Emp DOB

HasRelease

txtHRcontactName

txtHR employee ID

HRcontactemail

txtPayContactName

txtPayContactID

Work accommodation request

*** Browser requirement: Please use Microsoft Edge, Chrome, or Firefox to submit this form as certain functions do not work in Internet Explorer ***

_{* Browser requirement: Please use Microsoft Edge, Chrome, or Firefox to submit this form as certain functions do not work in Internet Explorer *}