Civil Rights Forms

ADA Reasonable Accommodations

for: Current Employees or Applicants

Requester's Name

Address

City

State

Zip

Home Phone #

Office Phone #

Cell Phone #

Work Location

Pre-Employment Applicants

During the pre-employment process, do you need any accommodations based on a disability under the Americans with Disabilities Act? (Example - materials in a different format)

Yes

If yes, what accommodations do you require?

Current Employee

If current employee, please provide supervisor's name.

Name of person making request, if third party.

What specific accommodation are you requesting?

If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore?

Yes

If yes, please explain

Is your accommodation request time sensitive?

Yes

If yes, please explain

What, if any, job function are you having difficulty performing?

What, if any, employment benefit are you having difficulty accessing?

What limitation is interfering with your ability to perform your job or access an employment benefit?

Have you had any accommodations in the past for this same limitation? (Even from a past employer)

Yes

If yes, what type of a accommodation was offered to you and how effective was it?

If you are requesting a specific accommodation, how will that accommodation assist you?

Please provide any additional information that might be useful in processing your accommodation request.