Fillable REASONABLE ACCOMMODATION REQUEST FORM

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REASONABLE ACCOMMODATION REQUEST FORM

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CONFIDENTIAL
Issued by CSCU System Office 03/20/2015
REASONABLE ACCOMMODATION REQUEST FORM
To be completed by employee or job applicant requesting an accommodation. Send to:
TDirector of Human Resources/Labor Relations
(203) 285-2537
This form must be used by college employees and/or applicants for employment who believe
they have a disability and wish to request a reasonable accommodation under the Americans
with Disabilities Act (ADA) or other applicable State and Federal civil rights laws. By considering
this request, the College does not consider or regard the person making the request as having a
disability as defined by the ADA, the Connecticut Fair Employment Practices Act, or any other
applicable law.
The purpose of this form is to assist the College in determining whether, or to what extent, a
reasonable accommodation is appropriate for an employee or applicant for employment. This
form must be maintained separately from the employee’s personnel file and is a confidential
document.
Fill out all sections that apply to you
Name:______________________________________ Date of Request_______________
Job Title/Classification:_________________________ Phone #: ____________________
Supervisor’s Name:____________________________ Phone #: ____________________
Department/Unit:_________________________________________________________
If job applicant, for what position are you applying? _____________________________
1. Identify the physical and/or mental impairment(s) for which you are requesting an
accommodation and expected prognosis/duration of the impairment(s).
2. Explain how the impairment(s) listed in #1 affects your ability to perform the essential
function(s) of the job/job applying for.
3. List the accommodation(s) you are requesting.
CONFIDENTIAL
Issued by CSCU System Office 03/20/2015
4. Medical verification of impairment from my physician or health care provider (check the
appropriate box):
[ ] I have enclosed the documentation for this request.
[ ] The disability and the need for reasonable accommodation is obvious and no
medical documentation is needed.
Explain:
I, __________________________, give Gateway Community College permission to explore
coverage and reasonable accommodations under the Americans with Disabilities Act of 1990,
and all applicable State and Federal laws. I understand that all information obtained during
this process will be maintained and used in accordance with the ADA, including its
confidentiality requirements.
______________________________ ______________________
Signature of Requestor Date
************************************************************************
To Be Completed By the ADA Coordinator
Accommodation Request is: Approved ____ Denied____ Modified____(Explain below)
Comments:
_______________________________ _____________________
Signature of ADA Coordinator Date
_______________________________ _____________________
Reviewed by Date
(if applicable for the college)
CONFIDENTIAL
Issued by CSCU System Office 03/20/2015
HEALTH CARE PROVIDER RELEASE FORM
I, _______________________________, give Gateway Community College permission to contact
(health care provider). I understand the reason for this contact is to advise the College about my
functional abilities and limitations in relation to my job functions. I understand that the College will
provide (health care provider) with specific information about the position, including the essential
functions and specific requirements. All information obtained from employee medical examinations and
inquiries will be job-related and consistent with business necessity. All information obtained will be
maintained and used in accordance with the Americans with Disabilities Act of 1990 confidentiality
requirements, and all other applicable State and Federal laws.
____________________________________________ __________________
Employee/Applicant Signature Date
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REASONABLE ACCOMMODATION REQUEST FORM

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Completed 2 September 2020

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