Cuesta College Hiring Packet 09/2009 Confidential ADA Request Form 2/9/2010
AMERICANS WITH DISABILITIES ACT (ADA)
Information and Accommodation Request Form
Definition: Under the ADA, an individual with a disability is a person who has –
a physical or mental impairment that substantially limits one or more major life activities;
Physical impairment is defined as
-- any physiological disorder, or condition, cosmetic disfigurement, or
anatomical loss affecting one or more of the following body systems: neurological, musculoskeletal, special
sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genito-urinary,
hemic and lymphatic, skin, and endocrine.
Mental impairment is defined as
-- any mental or psychological disorder, such as mental retardation, organic
brain syndrome, emotional or mental illness, and specific learning disabilities.
Major life activities
-- examples are: walking, speaking, breathing, performing manual tasks, seeing, hearing,
learning, caring for oneself, working.
a record of such an impairment; or
Example of a record of impairment
-- It protects people with a history of cancer, heart disease, or other
debilitating illness, whose illnesses are either cured, controlled or in remission. It also protects people with a
history of mental illness.
is regarded as having such an impairment.
This definition protects people who are "perceived" as having disabilities from employment decisions based on
stereotypes, fears, or misconceptions about disability. It applies to decisions based on unsubstantiated
concerns about productivity, safety, insurance liability, attendance, costs of accommodation, accessibility,
workers' compensation costs or acceptance by co-workers and customers.
As defined under the Americans with Disabilities Act, I feel I should be identified as disabled.
As defined under the Americans with Disabilities Act, I am not disabled.
For consideration and completion upon initial employment.
In order to perform the essential functions of the position, I would need the following accommodation (if
none, write none):
To request accommodation during the course of employment:
Needs unrelated to injury or illness on the job may be presented to the immediate supervisor and/or the
Executive Director of Human Resources & Labor Relations at anytime. (Written verification of need for
accommodation will be required). Reasonable accommodation will be made insofar as practicable.
Needs related to industrial injury or illness will be considered upon employee medical release to return
to usual and customary duties.
Print Name:
Signature:
Date:
Reference: Federal Americans with Disabilities Act of 1990; Education Code 87100-87107; Title V: Sections 53003, 53004, 53006, 53023-25
