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Disability Accommodations Request Form
Notice and Understanding Concerning Request for a Reasonable Accommodation
Accommodation Request:
I, ______________________________________, acknowledge and agree that if I revoke an authorization to
release health information addressed to a health care provider and signed by me for purposes of permitting
that health care provider to release certain information to Durham Technical Community College in support
of my request for a reasonable accommodation, I may not revoke any action that Durham Technical
Community College may have taken in reliance upon information disclosed, pursuant to the authorization
prior to the date of my revocation. I also understand that the federal Americans with Disabilities Act and
other applicable federal, state, and local laws require me to be an active participant in the interactive process
and to provide Durham Technical Community College with my health information that is necessary to
determine whether I am eligible for a reasonable accommodation and, if so, what the reasonable
accommodation will be. If I fail to cooperate in the interactive process or fail to provide the necessary
medical information, I understand that I will not receive a reasonable accommodation.
I understand that the information provided by a health care provider will become an employment record and
will be retained by Durham Technical Community College as required by law. I understand that the Health
Insurance Portability and Accountability Act does not apply to an employment record and the director of
Human Resources of Durham Technical Community College may disclose the information to others with a
business need to know for the purpose of evaluating alternative reasonable accommodations and
implementing an appropriate reasonable accommodation. Durham Technical Community College, however,
will comply with the requirements of the Americans with Disabilities Act and other applicable federal, state,
and local laws concerning the confidentiality of the information provided to it pursuant by my health care
I acknowledge that (i) I have read and understand this notice and (ii) I have received a copy of this notice for
my own records.
Employee’s Signature Date
Revised 6/2017
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