City of Chicago
EMPLOYEE/VOLUNTEER
Request for Reasonable Accommodation
This form is to be completed by a City of Chicago employee or volunteer. If additional space is needed to fully answer a
question, please attach a separate sheet of paper. Please sign and date all pages attached to this form.
If you need assistance completing this form or any part of the reasonable accommodation process, please
contact the City of Chicago Department of Human Resources at 312 -744-4224 (voice) or 312 -744-5035 (TTY).
When complete, this form may be submitted to the employee or volunteer’s departmental Disability Liaison or to the City of Chicago
Disability Officer. Please keep a copy for your records.
Although the City of Chicago must protect the confidentiality of medical information of its employees and applicants, please note
that medical information in this form, which is needed by the City of Chicago to carry out its obligations under the
Americans with Disabilities Act, as amended, is not considered “protected health information” under the
Health Insurance Portability and Accountability Act (HIPAA) and implementing regulations.
EMPLOYEE/VOLUNTEER INFORMATION
Name: _________________________________________________________________________________________
Home Phone: _____________________________________________ Work Phone: _______________________
Job Title: _______________________________________________________________________________________
Department: _________________________________________ Bureau/Division: ________________________
QUESTIONS TO DOCUMENT THE REASON FOR THE REQUEST
Do you have a physical or mental impairment which substantially limits one or more major life activities? Major life activities include, but are not limited
to eating, standing, walking, lifting, sleeping, breathing, seeing, hearing, concentrating, learning and working. Major life activities also include major
bodily functions, including but not limited to, functions of the immune system, special sense organs and skin; normal cell growth; and digestive,
genitourinary, bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, hemic, lymphatic, musculoskeletal, and
reproductive functions.
_______ Yes _______ No
If yes, please identify your impairment. If you have received a diagnosis please include that as well.
What, if any, job function(s) are you having difficulty performing as a result of your impairment?
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