This is a confidential form and will be submitted by the requesting applicant/employee directly to Human Resources. Only employees are expected to complete workplace information.
SECTION 1 – Applicant/Employee Information
Applicant/Employee Name:
Work Phone:	Cell Phone:
Home Phone:	E-mail:
For current employees, please complete workplace information:
Position:
Work Area:
Supervisor:
Position:
SECTION 2 – Physician Information
Please complete physician information: (The physician may receive a letter/fax from VDOF Human Resources requesting information on your impairment/disability and recommendations for accommodations.)
Physician Name:
Physician Address:
City:	State:	Zip:
Phone No.:	Fax No.:
SECTION 3 – Requested Accommodation
Nature of Qualifying Disability:
What, if any, job function do you have difficulty performing?
What, if any, employment benefit do you have difficulty accessing?
Requested/Suggested Accommodation: (Describe the accommodations you believe are needed to enable you to perform the essential functions of this job.)

SECTION 4 – Transitional Plan
A. Describe the specific duties/tasks that will be assigned. B. Describe any changes that are made in carrying out the duty due to the employee’s restrictions.
Start Date:	Planned End Date:
A. Specific Duties/Tasks	B. Adjustments
Schedule:
Special Considerations:
SECTION 5 – Employee Agreement
I have been provided with a copy of this plan and should I experience any difficulties during my transitional employment, I will discuss them with my supervisor. Any changes to these duties must first be discussed with Human Resource and approved by my treating physician.
Employee Name (Print)	Employee Signature	Date
SECTION 6 – Supervisor Acknowledgement
I acknowledge that I have reviewed the transitional plan and understand that any modifications to this plan must first be approved by the treating physician.
Supervisor Name (Print)	Supervisor Signature	Date