Formal Request for Reasonable Accommodation- Employee

(CONFIDENTIAL)

This form must be completed in order for a qualified disabled employee of the District to formally request reasonable accommodation. Your request will be processed as confidential in accordance with applicable law. As the employer, the District is ultimately responsible for determining what is a reasonable accommodation by reviewing all of the pertinent information and the needs of each employee on a case-by-case basis

Your request for reasonable accommodation will be reviewed and you will be notified by the District's decision in a reasonable time after this form is received by the ADA Coordinator.

The following to be completed by employee:

1. Your Name:__________________________________________________________________________________________
(please print)

SSN#/ID#: ____________________________________________

Status: ___Classified Staff      ___Faculty        ___Administrator

Address:________________________________________________________________________________________

City/State/Zip:___________________________________________________________________________________

Telephone number: (home)________________________________ (work)____________________________________

Current position:________________________________________ Div/Dept.:_________________________________

2.     Reasonable Accommodation Request:

What type of accommodation do you need?

__ Modified work schedule    __ Removal of communication barrier    __ Job Restructuring  
__ Change in procedure          __ Purchase of assistive services             __ Reassignment  
__ Purchase assistive device  __ Removal of architectural barrier         __ Other:
 
Please describe the accommodation: (use extra sheets if needed)

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Please explain how you believe this accommodation will enable you to perform the essential functions of your position: (use extra sheets if needed)

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

3.     Essential Duties of Your Position:

Please identify the essential duties (do not include marginal duties) of your position for which you are requesting an accommodation:

1. ______________________________________________________________________________________________

2. ______________________________________________________________________________________________

3. ______________________________________________________________________________________________

4. ______________________________________________________________________________________________

4.     Health Care Provider:

Please provide us with the name of your health care provider(s) who can assist with this request: (use extra sheet if needed)

Name:    _________________________________________________________________________________________

Address: _________________________________________________________________________________________

Phone: _________________________  Specialty: ________________________________________________________

5.     Major Life Activities:

Please check the major life activity(ies) you believe to be limited by your medical condition(s):

__ Walking    __ Breathing    __ Seeing    __ Caring for Oneself    __ Working __ Talking   
__ Hearing     __ Learning     __ Performing Manual Tasks            __ Other:

Please describe how the above activity(ies) is/are limited:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

6.  Is your medical condition temporary?  __ Yes   __ No
     If yes, please state the expected duration: _______________________________________________________________

7. Are you currently working? __ Yes   __ No
    If no, please specify the type of leave currently approved: ____________________________________________________
    If no, when do you expect to return to work? ______________________________________________________________
________________________________________________________________________________________

I hereby certify that I believe I am a qualified individual with a disability as defined by the law.  I have received and reviewed the information brochure and require an accommodation to perform the essential functions of my position.  I understand that a detailed review of my disability status may be required, and I agree to cooperate fully in this process.  I further understand that if my request is granted, I am obligated to report any changes in my disability status which may require a re-evaluation of this request.  Granting of this request does not  signify approval of any future reasonable accommodation request for any other position within the District or if applicable, any department within the City and County of San Francisco.

Signature: _______________________________________________________________ Date: ________________
(Employee)

Return this completed form to:       

AAO - 6 7/30/2003