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

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.

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

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

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 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

Email address

Department


Making facilities readily accessible.  For example, adding or updating an automatic door switch.

Job restructuring.  For example, changing the tasks you perform.

Part-time or modified work schedule.  For example, a change in work hours.

Acquisition of equipment or devices.  For example, a computer monitor, sit-to-stand desk or computer software.

Modification of equipment or devices.  For example:, a change to your current computer monitor, sit-to-stand desk or computer software.

Qualified reader or interpreter.  For example, software such as video remote interpreting or screen reader.

Other accommodation(s) not listed.  For example, telecommuting, job reassignment, or other adjustments not listed

How long do you anticipate this accommodation will be necessary?  Provide a start date and if applicable an end date.

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.


  Medical Provider information:



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.