Fillable Americans with Disabilities Act (ADA) Reasonable Accommodation Request (Palm Beach Schools)

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Americans with Disabilities Act (ADA) Reasonable Accommodation Request (Palm Beach Schools)

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THE SCHOOL DISTRICT OF PALM BEACH COUNTY
OFFICE OF EQUAL EMPLOYMENT OPPORTUNITY
Americans with Disabilities Act (ADA)
Reasonable Accommodation Request
This document contains confidential information that must be maintained separately from personnel
records in accordance with the Health Insurance Portability & Accountability Act (HIPAA).
Answer each of the following questions in the spaces provided. Attach additional pages as needed and number,
sign and date each additional page. Submit request to Professional Standards, Office of Equal
Employment Opportunity, 3300 Forest Hill Blvd., Suite A 106, West Palm Beach, FL 33406. Direct questions to
(561) 649-6866.
Employee First Name M.I. Last Name Employee ID #
School/DepartmentSubmit Date
Immediate Supervisor Immediate Supervisor's Title
To be eligible for a Reasonable Accommodation under the Americans with Disabilities Act of 1990, you must
have an impairment that substantially limits a major life activity such as, but not limited to, walking, speaking,
breathing, seeing, hearing, sitting, standing, lifting, learning, etc.
Identify and describe your impairment/disability.
How does your impairment limit a major life activity?
What specific job duties are affected due to your impairment or disability?
PBSD 2160 (Rev. 10/19/2016) ORIGINAL - Professional Standards, Office of Equal Employment Opportunity
page 1 of 2
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Employee Telephone #
Americans with Disabilities Act (ADA) Reasonable Accommodation Request continued
What type of accommodation(s) would enable you to perform the essential functions of your job?
Will you be able to perform the essential functions of your current job if you receive the accommodation?
Yes No
To adequately determine ADA eligibility and accommodation we request information from your treating
physician(s) and or health care specialist(s) regarding your disability and any resulting limitations. List
names, addresses, and phone numbers of the health care providers who have knowledge of your disability.
Physician's Name/Specialty/Address/Telephone #
Physician's Name/Specialty/Address/Telephone #
Physician's Name/Specialty/Address/Telephone #
IMPORTANT NOTE: To enable the School District of Palm Beach County to request medical information,
you will be required to complete and sign the Authorization for Release of Employee Medical Information
(PBSD 2161). Be aware that failure to provide such authorization for the District to obtain medical information
may result in a denial of your request for reasonable accommodation.
Number of attached additional signed and dated pages (required - if no attachments enter 0)
The foregoing request contains all relevant information that is factual, accurate, and complete. Any incomplete,
false, or misleading information submitted as part of this request may be cause for denial of your request for
accommodation.
Signature of Employee Date
page 2 of 2PBSD 2160 (Rev. 10/19/2016) ORIGINAL - Professional Standards, Office of Equal Employment Opportunity
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Americans with Disabilities Act (ADA) Reasonable Accommodation Request (Palm Beach Schools)

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Completed 10 February 2021

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