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NASSAU COMMUNITY COLLEGE REQUEST FOR REASONABLE ACCOMMODATION Title (Nassau Community College)

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NASSAU COMMUNITY COLLEGE
REQUEST FOR REASONABLE ACCOMMODATION
1
[AAO 10/2016]
Title II of the Americans with Disabilities Act (ADA) of 1990 requires employers to provide reasonable
accommodations for qualified employees with disabilities. This form provides a standard written
documentation of an employee’s request for reasonable accommodation and is to be submitted to the
Affirmative Action, ADA/504 Officer. The form may be submitted via the Department Head/Supervisor or
directly to the Affirmative Action, ADA/504 Officer. Completing this form is not a guarantee that the
request will be granted. Approved accommodations are subject to annual review.
Request From: _______________________________________ Date: __________________________
Position/Title: ______________________________________ Office Ext: ______________________
Department: __________________________________ Supervisor: ____________________________
Home Address: _______________________________________________________________________
___________________ Home Phone: _____________________ Cell Phone: ______________________
PLEASE BRIEFLY ANSWER QUESTIONS 1-5 BELOW: (Continued on page 2 of form).
1. What is your disability? What, if any, job function are you having difficulty performing?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. How does your disability impact your daily living outside of work?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
3. How does the disability impact your ability to perform your duties at work?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Describe what you think will help you effectively perform your job and how that
accommodation will assist you.
___________________________________________________________________________________
NASSAU COMMUNITY COLLEGE
REQUEST FOR REASONABLE ACCOMMODATION
2
[AAO 10/2016]
___________________________________________________________________________________
___________________________________________________________________________________
5. Please list and attach your medical documentation, if available. Verification may be required.
_______________________________ ________________________ _______________________
Signature of Employee Print/Type Employee Name Date Reviewed by AA Officer
Action(s) taken:
A. Interactive Process – Meeting held with Requestor and supervisor -- union representatives may
be present.
_____________________ _________ _________________________ _________
Date Initial Conference Date (if applicable) Initial
Outcome: ____________________________________________________________________
_____________________________________________________________________________
B. Granted/Approved __________________ C. Disapprove ______________________
__________________________ ______________
Craig Wright, ADA/504 Officer Date
*Approved accommodations are subject to annual review, and may require resubmitting of
medical documentation and/or update request form.
To be completed by Department Head/Supervisor: Would the requested accommodation, if granted,
fundamentally alter the position or impact any other employee’s job duties or position? Yes [ ] No [ ]
If yes, please explain and/or provide any other relevant information.
____________________________________________ _______________________________
Signed: Department Head/Supervisor Date Print Name: Dept. Head/Supervisor
(The department supervisor is responsible for implementing the accommodation, subject to approval.)
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NASSAU COMMUNITY COLLEGE REQUEST FOR REASONABLE ACCOMMODATION Title (Nassau Community College)

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Completed 26 July 2020

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