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Online Application

Important Messages

The purpose of this form is to assist the Disability Resource Center (DRC) in determining whether, or to what extent, a reasonable accommodation is required for a disabled or pregnant employee with a disability to perform the essential functions of his/her job safely and effectively. This form will be treated confidentially and filed at the DRC. It will be maintained separately from any personnel records.

You should receive an immediate email confirmation from, acknowledging the receipt of your application. Please contact if you have any questions regarding this process or have not been contacted within 72 hours of submission.
Personal Information
  1. Note: Select when you would like to start your services.
  2. Hint: Enter 8 alpha numeric characters.
Contact Information
  1. Hint: Enter 10-digit number only.
  2. Hint: Enter 10-digit number only.
  1. Relationship to Arizona (check all that apply)
  2. Have you previously communicated with a Workplace Access employee? If yes, specify their name in the textbox below. *
  3. Have you previously received an accommodation? If yes, please specify what type in the textbox below. *
  4. Please review the statement below, select the button to agree, and insert your initials in the textbox below. *

Terms and Conditions

By submitting this form, I acknowledge that it will be used for the purpose of beginning the interactive process to determine my eligibility for reasonable accommodation.

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