CONFIDENTIAL
Employee Disability Accommodations Request Form
An employee who wishes to request a reasonable accommodation should complete this form with a qualified health care
professional. The form and supporting documentation must be submitted to Human Resources. The form will be
maintained separately from the employee’s personnel file. For service animal requests and additional information, please
refer to the Accommodations for Employees with Disabilities policy
.
Documentation should be as descriptive as possible. At minimum, it should include the following information:
1. A diagnostic statement identifying the disability, date of the most current diagnostic evaluation, and the date of the
original diagnosis.
2. A description of the diagnostic tests, methods, and/or criteria used.
3. A description of the current functional impact of the disability which includes specific test results and the
examiner’s narrative interpretation.
4. Treatment, medications, and/or assistive devices/services currently prescribed or in use.
5. A description of the expected progression or stability of the impact of the disability over time, particularly during
the employee’s expected time at Durham Tech.
6. Recommended accommodations/services (i.e., flexibility in hours/duties, specialized furniture/equipment) for the
work environment.
7. The name, credentials, and license number of the diagnosing professional.
All documentation must be typed, signed by a qualified health care professional, submitted on the health care
professional’s letterhead, and include the date the documentation was completed. If the employee provides incomplete or
inadequate documentation to substantiate his or her disability and/or the need for the requested reasonable
accommodation, the College may, at its discretion, require the employee to provide additional information. The employee
is responsible for all associated expenses; the College is not financially responsible for any costs related to
documentation required to support the need for an accommodation.
EMPLOYEE INFORMATION
First Name: ____________________________________ Last Name: _________________________________________
ID Number: ____________________________________
Title: _________________________________________
Department: ___________________________________ Division: ___________________________________________
HEALTH CARE PROFESSIONAL INFORMATION
First Name: ____________________________________ Last Name: _________________________________________
Practice/Hospital Name: _________________________
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To Be Completed by the Employee and a Qualified Health Care Professional
A. Questions to help establish whether an employee has a disability.
A person has a disability under the ADA if
the person has an impairment that substantially limits one (1) or more major life
activities. The following questions may help determine whether an employee has a disability:
Does the employee have a physical or m
ental im pairment? Yes No
Des
cription of impairment:
The impairment is: Temporary Long-Term Permanent Not Sure
If not permanent, how long will the impairment likely last? _________________________________
Does the impairment affect a major life activity? Yes No
If yes, what life activity(ies) is/are affected?
Caring for Self
Sleeping
Learning
Walking
Performing Manual Tasks
Reproduction
Hearing
Reaching
Working
Lifting
Speaking
Toileting
Interacting with Others
Concentrating
Sitting
Standing
Breathing
Seeing
Thinking
Other (describe): ______________
________________________________________________________
Is the employee substantially limited in one or more of these major life activities? Yes No
B
. Questions to
help determine whether an accommodation is needed.
An em
ployee with a disability is entitled to an accommodation only when the accommodation is needed because of the
disability. The following questions may help determine whether the requested accommodation is needed because of the
disability:
What limitation(s) is/are interfering with job performance?
What job function(s) is/are the employee having trouble performing because of the limitation(s)?
How does the employee’s limitation interfere with his or her ability to perform the job function(s)?
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C. Questions to help determine effective accommodation options.
If an employee has a disability and needs an accommodation because of the disability, the employer must provide a
reasonable accommodation, unless the accommodation poses an undue hardship. The following questions may help
determine effective accommodations:
Do you have any suggestions regarding possible accommodations to improve job performance? If so, what are they?
How would your suggestions improve the employee’s job performance?
D. Comments
Employee Signature ____________________________________________ Date _____________________
Health Care Professional Signature ________________________________ Date _____________________
For Durham Technical Community College Use Only
Immediate Supervisor Signature:
Date Received:
Direc
tor, Human Resources Signature: __________________________________
Date Received: _________________
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