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LOS ANGELES UNIFIED SCHOOL DISTRICT R (Los Angeles Unified School District)

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LOS ANGELES UNIFIED SCHOOL DISTRICT
R
EASONABLE ACCOMMODATION APPLICATION
ATTACHMENT B
Bulletin No. 4569.1 Page 1 of 2 June 9, 2014
Division of Risk Management and Insurance Services
Directions: To be completed by the employee/applicant. Refer to Bulletin 4569.0 or the Reasonable
Accommodation Program for guidance.
Section I – Employee/Applicant Information
Employee/Applicant Name
Employee Number
Home Address
Home Phone Number
City
State
Zip Code
Work Number
Job Title
Worksite
Alternate Number
Do you have a previous request on file? Yes No
Section II – Request for Accommodations
members. In order to comply with this law, we are asking that you not provide any genetic information
when responding to this request for medical information.
LOS ANGELES UNIFIED SCHOOL DISTRICT
R
EASONABLE ACCOMMODATION APPLICATION
ATTACHMENT B
Bulletin No. 4569.1 Page 2 of 2 June 9, 2014
Division of Risk Management and Insurance Services
Section III – Outcome of Interactive Process
Mail fax or email (1) Attachment A - Interactive Process, (2) this form (Attachment B), and (3)
Medical documentation to:
Disability Coordinator
Division of Risk Management and Insurance Services
333 S. Beaudry Avenue, 28
th
Floor
Los Angeles, CA 90017
FAX (213) 241 – 6778
EMAIL disabilitymanagement@lausd.net
Please keep a copy for your records.
granted an exemption and/or accommodation and it is subsequently determined that the decision was
based upon material misrepresentation or falsification, I am subject to disciplinary action by the District,
my request will be cancelled, and/or I will be subject to reimbursing the District for related costs.
I further understand that this application, attachments, and all medical information subsequently
requested will be considered as confidential medical information and will be retained by the Los Angeles
Print Name of Employee/Applicant
Date
Signature of Employee/Applicant
Phone Number
Email Address
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Completed 23 June 2021

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