LOS ANGELES UNIFIED SCHOOL DISTRICT ATTACHMENT A
RECORD OF INTERACTIVE PROCESS
BUL-4569.1 Page 1 of 1 June 9, 2014
Division of Risk Management & Insurance Services
Directions: To be completed by site administrator/supervisor in discussion with employee/applicant. Please
review the class description/job analysis if available together with the employee/applicant and answer the
questions below. Refer to this Bulletin or the Reasonable Accommodation Program for guidance on conducting
the interactive process.
Mail, fax or email form to:
Disability Coordinator, Division of Risk Management and Insurance Services
333 S. Beaudry Avenue, 28
Floor, Los Angeles, CA 90017
FAX: (213) 241-6778
Please keep a copy for your records.
Section I – Employee/Applicant Information
Does the employee have a previous reasonable accommodation request on file? No Yes, date:
Section II – Documentation of Interactive Process (attach additional sheet(s) if necessary)
a) Date(s) of meeting with employee/applicant (in person):
b) What symptoms or limitations affect the employee’s performance of the essential job functions?
c) What specific job tasks are problematic as a result of these symptoms and limitations?
d) Possible accommodation(s) identified? Yes No Explain.
Section III – Outcome of Interactive Process
Were informal accommodation made at the school site/office?
Section IV – Certification
Print Name of Site Administrator/Supervisor
Signature of Site Administrator/Supervisor