California State University, Los Angeles
CONFIDENTIAL
Americans with Disabilities Act (ADA)
Request for Reasonable Accommodation
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Please complete and return along with your Request for Reasonable Accommodation Form.
This release will be submitted to your doctor(s) in the event that additional information is needed
regarding the medical condition(s) for which you are requesting reasonable accommodation(s).
1. Name:
Employee I.D. No.
_________
2. Home Address:
_______ Home Phone:
__________
3. Department:
Job Title: ____________________ Ext: _________________
4. Physician’s Name:
____________________
Phone:
_____________________
Address:
Fax:
____________
5.
Physician’s Name:
____________________
Phone:
_____________________
Address:
Fax:
____________
I hereby authorize California State University, Los Angeles, or its agent, to contact Dr.(s):
to request and obtain information about my functional abilities, my functional limitations, and any
requirements for reasonable accommodation for which I am requesting a reasonable accommodation(s).
Signature:
Date:
For use only by the Office for Equity and Diversity. 09/2011
