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AMERICAN WITH DISABILITIES ACT
APPLICATION FOR ACCOMMODATION
Rev. 11/14/18
The Americans with Disabilities Act of 1990, as Amended (ADA) prohibits employers from discriminating against
individuals with disabilities. The ADA also prohibits retaliation against an employee for taking any action pursuant to the
Act.
Definition of Disability: The ADA states that an individual is disabled if she/he:
•
has a physical or mental impairment that substantially limits one or more of the individual’s major life activities;
•
has a record of such an impairment; or
•
is regarded as having such an impairment.
Definition of Qualified Individual: The term “qualified individual with a disability” means:
•
An individual with a disability,
•
Who can perform the “essential functions” of the
employment
position,
•
With or without reasonable accommodation.
Employers are required to provide job accommodation to the known limitation(s) of a person with a disability, as defined
by the Americans with Disabilities Act.
A job
accommodation is a reasonable adjustment to a job or work environment that makes it possible for an individual
with a disability to perform job duties. Determining whether to provide accommodations involves considering the
required job tasks, the functional limitations of the person doing the job, the level of hardship to the employer, and other
issues. Accommodations may include specialized equipment, facility modifications, adjustments to work schedules or job
duties, as well as a whole range of other creative sol
utions.
S
elf-Disclosure: In order to establish the existence of a disability and request reasonable accommodation under the ADA,
an employee must complete and submit a Request for Disability Accommodation Form. The form can be submitted to
the Department of Human Resources.
A copy of the ADA Request form should be provided to your department chair or supervisor to ensure that
accommodations can be made in quick and professional manner.
AMERICAN WITH DISABILITIES ACT
APPLICATION FOR ACCOMMODATION
Rev. 11/14/18
Faculty and Staff Accommodation Procedures
Step 1) Documentation of Disability:
When an employee submits a Request for Disability Accommodation Form, she/he must provide, at his/her own expense,
documentation for his/her disability in the form of a written evaluation by an appropriate health care provider. The
employees’ health care provider must describe the following:
1) Information regarding the employee’s medical disability outlining sp
ec
ific medical words and terminology.
2) Outline the limitations caused by the disability and note
rec
o
mme
n
de
d job accommodations.
3) D
escribe the length of time that the employee will need to have job accommodations due to his/her
disability.
4) If a disability arise due to an incident, the employee’s medical provider should explicitly clear employee to
return to work.
Step 2) Temporary Accommodations:
After consultation with the employee and his/her department chair or supervisor, the Department of Human Resources
may provide the employee with a temporary accommodation pending receipt and
ev
alu
at
ion of the documentation of
the disability. The Department of Human Resources will notify the employee of the temporary accommodation to be
provided.
Step 3) Evaluation of D
ocumentation:
Upon receipt of documentation from an employee’s health care provider, the University will determine if the employee
has a disability as defined by the ADA, and if the employee can perform the essential functions of her/his position, with
or without reasonable accommodation.
Step 4) Final Determination and Notification to Staff or Faculty Members:
The University has the authority to make a determination regarding what accommodation, if any, is appropriate. When
a final determination is made, the Department of Human resources will notify the employee of th determination,
whether an accommodation has been granted, and if so, will specify what accommodation has been granted. The
Department of Human Resources will also notify the employee’s department chair and/or supervisor if an
accommodation is to be provided to the employee.
AMERICAN WITH DISABILITIES ACT
APPLICATION FOR ACCOMMODATION
Rev. 11/14/18
Employee Request for Disability Accommodation Form
Employee Name:
Employee ID:
Home Address:
City/State/Zip Code:
Home/Cell Number
Work Phone:
Job Title:
Department:
Supervisor’s Name:
1) Please provide a brief description of your essential job functions and responsibilities
Essential functions are fundamental, crucial job duties performed in a position.
For example: if you are a custodian, essential job functions/responsibilities are vacuuming, sweeping, etc.)
2) Please describe the disability for which you are requesting accommodation
• An Individual with a disability is a person who:
- Has a physically or mental impairment that substantially limits one or more major life activity; or
- Has a record of such impairment; or
- Is regarded as having such an impairment
AMERICAN WITH DISABILITIES ACT
APPLICATION FOR ACCOMMODATION
Rev. 11/14/18
3) Describe how your disability/limitation affects your ability to perform one or more essential functions of your
job:
4) What specific job accommodation is needed to perform your essential job functions?
A job accommodation is a reasonable adjustment to a job or work environment that makes it possible for an
individual with a disability to perform job duties. Determining whether to provide accommodations involves
considering the required job tasks, the functional limitations of the person doing the job, the level of hardship to
the employer, and other issues. Accommodations may include specialized equipment, facility modifications,
adjustments to work schedules or job duties, as well as a whole range of other creative solutions.
5) How long do you anticipate the need for an accommodation?
6) Has a physician, vocational rehabilitation specialist, or other health professional recommended a
specific accommodation? ☐ Yes ☐ No
If yes, please attach a copy of their recommendations. If you do not have the documentation, please
have your treating physician complete the “Request for Disability Accommodation Form Completed by
Treating Physician”.
AMERICAN WITH DISABILITIES ACT
APPLICATION FOR ACCOMMODATION
Rev. 11/14/18
Confidentiality Policy
All documentation is confidential and used by the Department of Human Resources for the purposes of
consideration for ADA accommodation only and will not be placed in your employment file. Such information
may be shared on a strict need-to-know basis with appropriate University administrators. When supervisors are
informed of an employee’s limitations and accommodations, disclosure of the employee’s medical information
and status as an employee with a disability is prohibited.
Employee Signature:
Date:
Supervisor Signature:
Date:
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Completed 19 July 2020

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