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ADA Request Form

Please complete the form below. Required fields marked with an asterisk *

Contact Information

Last Name*

Answer required for "Last Name"

First Name*

Answer required for "First Name"

Cell Phone*

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Position*

Answer required for "Position"

School/Building*

Answer required for "School/Building"

Please describe which major life activity your impairment limits? *

Answer required for "Please describe which major life activity your impairment limits? "

Describe how your condition limits your ability to perform the essential functions of your job? *

Answer required for "Describe how your condition limits your ability to perform the essential functions of your job? "

Identify possible accommodation that may enable you to perform the essential functions of the job? *

Answer required for "Identify possible accommodation that may enable you to perform the essential functions of the job? "

How will the accommodation enable you to perform the essential functions of your job? *

Answer required for "How will the accommodation enable you to perform the essential functions of your job? "

IMPORTANT ADDITIONAL INFORMATION

Employees must send the Office of Human Resources a letter from their medical provider containing the following information:

The medical conditions(s) of the employee in reference to their request for accommodations based on the ADA (Americans with Disabilities Act).
How the disability limits the employees performance of essential functions of the position.
Identify possible accommodations that may enable the employee to perform the essential job functions.
How will the medical provider's suggestions will improve the employee’s ability to perform the essential job functions?
How long do the medical provider expect this accommodation to be necessary?

Confirmation*

Answer required for "Confirmation"

I certify that the information provided is true and accurate.

Confirmation Email

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