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?

Region is required

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:

Use only alphanumeric characters for job number

Use only alphanumeric characters for job position

Job Seeker Contact Information

Use only alpha characters for last name

State is required.

Use only numeric characters

Provide valid alternate email

Is this accommodation for yourself or for someone else?

Accommodation field is required.

What type of accommodation are you requesting?

Type of Accommodation is required.

What is the expected duration of the accommodation?

Accommodation duration is required.

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