San Francisco Community College District

Reasonable Accommodation Request: Use of a Motorized Scooter

SHORT FORM

FOR USE BY CCSF EMPLOYEES

(CONFIDENTIAL)

The District has a limited number of motorized scooters available for use on the Ocean Campus as a reasonable accommodation by those employees who have disabilities as defined in the law. The brochure accompanying this short form will provide you with an overview of the process for employees with disabilities.

In order to expedite the process for everyone concerned, if you wish to apply for motorized scooter use, simply complete the information below and submit it to the Title 5/ADA Compliance Office directly at 31 Gough Street, Room 9A, or you can submit it to a DSP&S representative and it will be forwarded to the Title 5/ADA Compliance Office. Information regarding the forms and procedure for applying for a reasonable accommodation under the disability laws covering employees will be mailed to you.

Request for Use of a Motorized Scooter

Employee Name: ____________________________________________________________

Home Address: ______________________________________________________________

______________________________________________________________

Position/Job Classification: ____________________________________________________

Restriction Requiring Scooter Use: ______________________________________________

Anticipated Length of Time Scooter Needed

From: __________ To: ________________

I understand that use of a motorized scooter will be limited to two weeks pending submission of my reasonable accommodation request to the Title 5/ADA Compliance Office.

________________________________________________________ ______________

Employee’s Signature Date