Fill - Free fillable AD Aapplication Form2017 (Marquette University) PDF form

PROCEDURE FOR REQUESTING AN ADA REASONABLE ACCOMMODATION

1. Follow the steps below to initiate the process.

a. The employee completes an ADA Reasonable Accommodation Request Form

(Attachment A) to acknowledge that the request is being made.

b. The employee gives the Medical Information memo (Attachment B) and the

Certification of Physical Disability/Medical Condition Form (Attachment C) to

his/her physician who, in turn, will provide the required medical information.

c. The employee then submits the ADA Reasonable Accommodation Request

Form to the Human Resources Department.

The Certification of Physical Disability/Medical Condition form and any

additional medical information (records) should be submitted by the employee

or medical provider to the Human Resources Department for a reasonable

accommodation review. Documents should be sent to:

Marquette University Office of Human Resources, Straz Tower #185,

P.O. Box 1881

Milwaukee, WI 53201-1881

Telephone (414)288-7305

FAX (414)288-7425

d. If you have any additional questions regarding the ADA reasonable accommodation

application process, please contact Lynn Mellantine, Assistant Vice President of Human

Resources, Straz Tower 185, ext. 8-3430, lynn.mellantine@marquette.edu

An accommodation that is medically necessary is one that has a risk-avoiding or therapeutic value

associated with the accommodation and will enable the employee to perform the essential functions of

his/her job. On the other hand, if the review concludes that, based upon the accommodation

assessment of the employee’s medical information, an accommodation is not medically necessary or is

not likely to be effective, the request for the accommodation may be denied.

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C O N F I D E N T I A L

REQUEST FOR ADA REASONABLE ACCOMMODATION FORM

(ATTACHMENT A)

Please complete the ADA Reasonable Accommodation Request form and submit the completed form

to the Human Resources Department. Information received pertaining to an accommodation request

is kept confidential to the extent possible and maintained separately from personnel records.

I. Employee Personal Information

Name: __________________________ Ext______ Job Title: _______________________________

Department: ________________________ Supervisor’s Name: _____________________________

II. Describe the essential functions of your job that you are unable to perform and the

reasons why (attach additional page(s) if necessary). (Medical information pertaining to

your disability will be required.)

__________________________________________________________________________________

III. Describe the accommodation(s) requested (attach additional page(s) if necessary):

__________________________________________________________________________________

______________________________________

Employee Signature/Date

HR 01/2017

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C O N F I D E N T I A L

MEDICAL INFORMATION

(ATTACHMENT B)

Please provide medical information from your medical doctor that describes your medical

condition and describes any limitations placed on your major life activities and functions.

Please be certain to inform your doctor that your request for medical information is being made

because you have applied for an ADA reasonable accommodation. Additionally, request that your

doctor review the standards for the medical documentation information review listed below so that

his/her reply provides the medical information requested to review your request in an efficient and

thorough manner.

Medical information to be provided by a qualified health professional and attached to the

Request for ADA Reasonable Accommodation Form:

1. Include a statement of the specific diagnosis of the disability.

2. Cite the diagnostic criteria and tests given, with dates (no more than 3 years since

administration) results, and interpretations. Cite how the results support the diagnosis.

3. Describe the applicant's functional limitations due to the disability, and the impact of those

limitations on physical, perceptual and cognitive abilities.

4. Recommend specific accommodation(s) and for each accommodation, provide a rationale

as to how it will reduce the impact of the functional limitation(s).

5. State your professional credentials and any licenses you hold that support your

qualifications to diagnose and/or treat this applicant's disabilities.

6. Send Documents to:

Marquette University Office of Human Resources, Straz Tower #185,

P.O. Box 1881

Milwaukee, WI 53201-1881

Telephone (414)288-7305

FAX (414)288-7425

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CERTIFICATION OF PHYSICAL DISABILITY/MEDICAL CONDITION

(ATTACHMENT C)

The employee named below has applied for coverage under the American with Disabilities Act at

Marquette University. In order to determine this employee's eligibility for reasonable and appropriate

accommodations, we ask that you provide current and comprehensive information attesting to the

employee's disability and documenting the functional impact of the disability.

Please take into consideration when completing this form:

1. All parts of the form must be completed as thoroughly as possible. Inadequate information,

incomplete answers and/or illegible handwriting may delay the eligibility review process by

necessitating follow up contact for clarification.

2. The healthcare provider should attach any reports which provide additional related information.

If a comprehensive diagnosis report is available that provides the requested information; copies

of that report can be submitted for documentation as well.

If you have any questions please call the Office of Human resources at 414-288-7305. Thank you for

your assistance.

Name of employee: ____________________________________ Date: ______________________

1. Is this employee currently under your care? _____Yes _____No

2. When did you last see this employee? ____________________________________

3. What is the diagnosis of the impairment? (Please use definitive language and avoid such

speculative language as “suggests” or “could have problems”)

____________________________________________________________________________

Date of diagnosis: _____________________________________________________________

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Section I

Major Life Activities Assessment

Please check which of the major life activities listed below are substantially limited because of the

current condition. (Substantially limited is defined as a "significant restriction in the condition, manner,

or duration in which a major life activity is performed compared to most people.")

Talking _____ Seeing _____

Hearing _____ Sleeping _____

Breathing _____ Learning _____

Standing _____ Thinking _____

Working _____ Concentrating _____

Reaching _____ Memorizing _____

Lifting _____ Writing _____

Sitting _____ Interacting w/others _____

Walking _____ Caring for oneself _____

Speaking _____ Reading _____

Employment Effects

I. How does this condition/impairment impact the employee’s ability to perform his/her job? If

this condition/impairment does not affect the employee’s ability to work, please explain.

_________________________________________________________________________

a. If the employee is currently undergoing medical treatment, please describe and indicate

how this treatment might affect the employee’s work.

_________________________________________________________________________

b. Are there any situations that might lead to an exacerbation of the condition/impairment?

_________________________________________________________________________

HR 01/2017

c. Please provide specific job accommodations with justification as to why these

accommodations would be appropriate for the employee. *Please note - There may be

limitations on the number of absences an employee is allowed based on job

requirements.

i. Accommodation: __________________________________________________

________________________________________________________________

Justification:______________________________________________________

________________________________________________________________

ii. Accommodation: __________________________________________________

________________________________________________________________

Justification:______________________________________________________

________________________________________________________________

Accommodation:__________________________________________________

________________________________________________________________

Justification:______________________________________________________

________________________________________________________________

Is there anything else you would like us to know about this employee?

__________________________________________________________________________________

Section II

Please sign, date and return to the employee.

_______________________________________________ ________________________

Signature of Treating Professional Date

_______________________________________________ ________________________

Professional's Name (printed) License Number

_______________________________________________ ________________________

Professional’s Title Telephone Number

_______________________________________________ ________________________

Address Fax Number

HR 01/2017

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