Name:

Dept:

Supervisor:

Position:

1. What specific accommodation are you requesting?

1a. If unsure, do you have any suggestions that we can explore? If yes, please explain:

2. Is your accommodation request time sensitive? If yes, please explain:

3. Please identify your limitation(s):

4. What is the expected duration of this limitation?

5. What, if any, job function(s) are you having difficulty performing due to
this limitation?

6. What, if any, employment benefits (i.e. parking, architectural barriers,
etc.) are you having difficulty accessing?

7. Have you previously received an accommodation for this limitation? If yes, what were they and how effective were they?

8. Please provide additional information that might be helpful to process
your request.

Return this form to:
Robert Sinibaldi, ADA Coordinator
The Town of Merrimac
4 School Street
Merrimac, MA 01860
TEL: (978) 346-0525
EMAIL: commissioner@townofmerrimac.com

The Town of Merrimac is committed to providing reasonable accommodations for qualified individuals with disabilities in a fair and equal manner and in accordance with applicable federal and state law unless doing so represents an undue hardship.