Kaiser accommodation request form

Please fill out the fields below and click "submit" to send your Accommodation Request. All sections must be completed unless otherwise noted.

In which region is the job seeker submitting for a job?

Is the job seeker submitting for multiple positions?

If known, please provide the specifics of the job(s) for which the job seeker is submitting:

Job Seeker Contact Information

Is this accommodation for yourself or for someone else?

What type of accommodation are you requesting?

What is the expected duration of the accommodation?

When is the accommodation needed (if known)?

The information you provide will be maintained in a confidential manner. It will only be disclosed on a strict business need to know basis for the purpose of assessing and providing the requested accommodation. KP may request written documentation from the employee's/job seeker's health care provider. The employee/job seeker is responsible for providing KP with medical documentation that assists KP in assessing the employee/job seeker's functional limitations to determine possible reasonable accommodations. If an employee/job seeker fails to provide necessary medical information, KP may not be obligated to provide an accommodation.

New Accommodation Request