Name:
Organization:
Street Address:
Address (cont.):
City:
State/Province:*
Zip/Postal Code:
Country:
E-mail:*

My primary role is that of: Other:

Would you like to join our mailing list? Yes No

Explain the nature of your information request in your own words. Provide as much detail as possible.

When you have completed your entries, click on the "submit form" button below, and your information request will be electronically mailed to the Work RERC project staff. If you need to clear your responses and start over, click on the "reset form" button below.

>> Return to RERC Home Page

This is a publication of the RERC on Workplace Accommodations, which is supported by Grant H133E020720 of the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education. The opinions contained in this publication are those of the grantee and do not necessarily reflect those of the U.S. Department of Education.

Rehabilitation Engineering Research Center on Workplace Accommodations
Center for Assistive Technology and Environmental Access � Georgia Institute for Technology
490 10th Street � Atlanta, GA 30318
Telephone: 800-726-9119 (Voice/TTY) � Fax: 404-894-9320 � Email: