Employee Request for ADA Accommodation/Modification
Office of Human Resources and Development (OHRD)
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
MCPS Form 270-6
June 2021
INSTRUCTIONS
Employees must use the electronic or PDF versions of this form when requesting an accommodation or modification under the Americans
with Disabilities Act Amendments Act of 2008.
Employees must attach related medical documentation. The medical documentation only needs to include information related to your
request for accommodations, MCPS does not need a full medical record or any information related to other medical conditions if they are
not related to your accommodation request. All medical information is kept in a secure, confidential medical file and is not shared with your
principal and/or supervisor and is not placed in your personnel file. If the disability is obvious or already known to MCPS, documentation
is not necessary. This information should include:
• the nature, severity, and duration of the impairment, medical condition or disability
• the life function, activity or activities that the impairment, medical condition or disability limits (for example, breathing, walking,
executive function, etc.)
• the extent to which the impairment, medical condition or disability limits your ability to perform the activity or activities on-site, and
• why the requested reasonable accommodation is needed.
Employees are highly encouraged to use the electronic version of this form found online: http://www.montgomeryschoolsmd.org/
departments/forms/detail.aspx?formNumber=270-6&catID=1&subCatId=19. Forms can be emailed to ADArequests@mcpsmd.org.
Questions about ADA accommodations or modifications may be directed to the Department of Compliance and Investigations (DCI)
240-740-2888.
PART I: TO BE COMPLETED BY THE REQUESTER AND SUBMITTED TO DCI
Name: Last ___________________________________________________________First________________________________________MI______
Employee ID_______________ Preferred Phone _____-_____-______ Work Location _______________________________________________
Describe requested accommodation/modification
Provide the reason for the request (Attach related medical documentation.)
Requestor Signature
___________________________________________________________________________________ Date ____/____/_____
PART II: COMPLETED BY DCI
o Resolved
o
Not Resolved Explain
o Referred to school/office
Signature
____________________________________________________ Title ___________________________________ Date ____/____/_____
Note: This document is available in alternative format upon request. Contact the Department of Communications, Montgomery County Public Schools,
850 Hungerford Drive, Rockville, MD 20850. Telephone 240-740-2837.
