NORWALK-LA MIRADA UNIFIED SCHOOL DISTRICT
DIVISION OF HUMAN RESOURCES
12820 PIONEER BLVD., NORWALK, CA 90650
562-210-2401 FAX 562-864-9857
REQUEST FOR REASONABLE ACCOMMODATION
In accordance with the California Fair Employment and Housing Act and ADA requirements, employees requesting
reasonable accommodations to perform essential functions of their job may complete this form and submit to the Division
of Human Resources to begin the interactive process.
NAME OF EMPLOYEE: POSITION/JOB TITLE:
SITE/DEPARTMENT: NAME OF SUPERVISOR:
EMAIL ADDRESS: PHONE NUMBER:
ACCOMMODATION(S) REQUESTED (Be as specific as possible):
REASON FOR REQUEST (Please do not disclose any medical diagnosis; explain your work restriction(s) and how any proposed
accommodation(s) will help you complete your essential job duties.):
IS YOUR WORK RESTRICTION:
START DATE OF WORK
RESTRICTION:
ANTICIPATED END DATE OF WORK
RESTRICTION:
HAVE YOU REQUESTED FMLA, CFRA, EPSLA OR USE OF OTHER LEAVE IN CONNECTION WITH THE REASON DESCRIBED ABOVE?
YES
NO
If yes, please specify type of leave and dates:
My signature below signifies that the information provided above is accurate and complete.
I have attached a Doctor’s note and all available supporting documents and provided any additional necessary information.
EMPLOYEE SIGNATURE: DATE:
click to sign
signature
click to edit
![]()
