Fillable CI Reasonable Accommodation Request Form ( (California State University Channel Islands)

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CI Reasonable Accommodation Request Form ( (California State University Channel Islands)

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CSU CHANNEL ISLANDS REASONABLE ACCOMMODATION REQUEST FORM
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CSU CHANNEL ISLANDS REASONABLE ACCOMMODATION REQUEST FORM
POSITION APPLYING FOR OR HOLDING
This form should be completed when an applicant or employee indicates his or her desire to request a reasonable
accommodation from the California State University Channel Islands (CI). Upon completion, this form must be
delivered to Human Resources and kept separate from the applicant’s/employee’s personnel file.
The purpose of this form is to assist CI in determining whether or to what extent a reasonable accommodation
can be made for an applicant or employee to safely and effectively perform the essential functions of his or her
present job or the job he or she is seeking.
TO BE COMPLETED BY THE APPLICANT OR EMPLOYEE
1. Identify and describe any current medical work restrictions on your ability to perform your
current job duties (please attach documentation from a licensed healthcare professional if
currently available) which form the basis for your request for reasonable accommodation(s) by
CI:
2. Identify and describe the essential function(s) of your position or the position you seek which
you are unable to perform without reasonable accommodation(s) (see definition of “reasonable
accommodation” below):
3. Identify and describe the reasonable accommodation(s) needed to enable you to properly and
safely perform the essential functions of your job or the job you seek, including special equipment,
changes in the physical layout of the job, or other accommodations:
NAME
DEPARTMENT SUPERVISOR
Print Form
CSU CHANNEL ISLANDS REASONABLE ACCOMMODATION REQUEST FORM
2
4. Identify and describe any equipment, aids, or services that you feel are necessary to allow you
to perform the essential functions of your job or the job you seek:
5. Identify the name, address and telephone number of the licensed physician, therapist,
psychologist, or other licensed healthcare professional who can help the University determine the
appropriate reasonable accommodation based on your current medical work restrictions:
I hereby authorize the above-listed health care provider(s) to release to California State
University Channel Islands information concerning the medical restrictions disclosed herein
and provide any opinions to them concerning my ability to perform essential job-related
functions with or without reasonable accommodation.
I certify that I have read and reviewed the position description for my current position (or
position I am seeking) or have been informed of the essential functions of my job. I further
certify that the foregoing statements are complete, accurate, and true to the best of my
knowledge, and I understand CI may require me to undergo testing or evaluation by medical
personnel retained by the CI for the purpose of establishing the existence and extent of any work
restrictions that may affect my ability to perform essential job-related functions with or without
reasonable accommodation.
●"Disability" includes a physical or mental impairment that limits one or more major life
activities, having a record or history of such impairment, or being perceived or regarded as
having such impairment. Major life activities include such things as caring for oneself,
performing manual tasks, walking, sitting, standing, lifting, reaching, seeing, hearing,
breathing, learning, and working.
●"Reasonable accommodation" for an employee includes any modification to the job or work
environment to enable an employee to perform the essential functions of the job in question.
For an applicant "reasonable accommodation" includes making appropriate changes or
adjustments to allow an applicant with a disability the opportunity to compete for a job
opening.
These definitions are provided only as a guide for completing this form. Nothing in this form is intended to alter the
legal definitions of these terms or impose obligations on the CI not required by law.
Applicant’s/Employee’s Signature
Date
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CI Reasonable Accommodation Request Form ( (California State University Channel Islands)

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Completed 24 July 2020

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