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ADA Request Form

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

Contact Information

Last Name*

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First Name*

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Cell Phone*

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Position*

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School/Building*

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Please describe which major life activity your impairment limits? *

Answer Required

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

Answer Required

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

Answer Required

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

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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*

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I certify that the information provided is true and accurate.

Confirmation Email

Enter your email address here if you'd like to receive a confirmation upon submitting the form.

Email Required