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
Employee First Name M.I. Last Name Employee ID #
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
Employee Telephone #