If you have any questions about this process, please contact the ADA Coordinator at 463-5589.
LANE COMMUNITY COLLEGE REQUEST FOR ACCOMMODATION
Name:
Date:
L number:
Position:
Campus Address:
Supervisor/Department:
Day Phone:
Employee e-mail:
What accommodation are you requesting? Please be specific, including any auxiliary aids, barrier
removal or services that can be provided.
If you are not sure what accommodation is needed, do you have any
suggestions about what options we can explore?
Yes
No
If yes, please explain.
Is your accommodation request time sensitive?
Yes
No
If yes, please explain.
What, if any, job function(s) are you having difficulty performing?
What, if any, employment benefit are you having difficulty accessing?
What limitation (as a result of a disability) is interfering with your ability to perform your job or access an
employment benefit?
Have you had any accommodations in the past for this same condition?
Yes
No
If yes, what were the accommodations and how effective were they?
If you are requesting a specific accommodation, how will that accommodation assist you?
Please attach the “Medical Inquiry Form in Response to an Accommodation Request” completed by your
physician. This documentation will be necessary in order to evaluate your request for accommodation.
In addition to the “Medical Inquiry Form”, your physician should provide a diagnostic statement, on
letterhead, identifying your impairment, the date of the most current diagnostic evaluation and the date of
the original diagnosis. Please attach to form.
Please attach any additional information that might be useful in processing your accommodation
request.
_____________________________________________________/_____________________
Employee’s Signature Date
Return this form to the ADA Coordinator at:
LCC Human Resources
4000 E 30
th
Avenue Bldg 3
Eugene, Oregon 97405
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