Accessibility Services Request Form (For Employees)

Learn more about Accessibility Information for Employees by clicking here.

If you have any additional questions about this form or the process of requesting accommodations, please call 201-360-4157 / 4163, or email asFREEHUDSONCOUNTYCOMMUNITYCOLLEGE.

Two Ways to Request Services

Download and fill out the Employee Accommodation Request Form, and send it to asFREEHUDSONCOUNTYCOMMUNITYCOLLEGE.
(Screen reader compatible form available here.)

OR
Fill out the form below.

* Required field.

Please don't fill out this input box.

First Name*

Last Name*

Position*

Department*

Employee ID*

Cell Phone*

Campus Extension

College Email*

Status*

Staff

Faculty

Campus*

Journal Square

North Hudson

Supervisor's Name

Supervisor's Email

Supervisor's Campus Extension

Describe the nature, severity and duration of your disability which supports your request for a reasonable accommodation.*

If applicable, describe how your condition interferes with your ability to perform the essential functions of your job.

Describe the accommodation(s) that you believe would enable you to perform the essential functions of your job.

IMPORTANT!

After submitting the form, please continue to Step 2 from the "Employee Process for Requesting Accommodations" in the Accessibility Information for Employees page to complete the Employee Medical Inquiry Form.

Contact Information

Danielle Lopez
Director of Diversity, Equity and Inclusion for Accessibility Services

(201) 360-5337

dlopezFREEHUDSONCOUNTYCOMMUNITYCOLLEGE

Karine Davis
Coordinator, Accessibility Services

(201) 360-4163

kdavisFREEHUDSONCOUNTYCOMMUNITYCOLLEGE
https://calendly.com/kdavishccc

Journal Square Campus
71 Sip Ave., Room L010/L011
Jersey City, NJ 07306
(201) 360-4157
asFREEHUDSONCOUNTYCOMMUNITYCOLLEGE

North Hudson Campus
4800 John F. Kennedy Blvd., 7th Floor (Room 703P)
Union City, NJ 07087
(201) 360-4157
asFREEHUDSONCOUNTYCOMMUNITYCOLLEGE