Fillable REQUEST FOR REASONABLE ACCOMMODATION-CONFIDENTIAL (California)

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REQUEST FOR REASONABLE ACCOMMODATION-CONFIDENTIAL (California)

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The REQUEST FOR REASONABLE ACCOMMODATION-CONFIDENTIAL (California) form is 5 pages long and contains:

  • 3 signatures
  • 8 check-boxes
  • 61 other fields

Country of origin: US
File type: PDF

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1
REQUEST FOR REASONABLE ACCOMMODATION-CONFIDENTIAL
The Calif
ornia Fair Employment and Housing Act requires employers of five or more employees to provide reasonable
accommodation for individuals with a physical or mental disability to perform the essential functions of their job unless it would
cause an undue hardship. The law does not require the use of this or any other form to make a request for a reasonable
accommodation. This form and any supporting materials or information is confidential and should be kept separate from an
employee’s personnel file.
IS THE ABOVE DESCRIBED DISABILITY THE SUBJECT OF A WORKER’S COMPENSATION CLAIM? (Employees with work related
injuries may also be eligible for a reasonable accommodation independent of the worker’s compensation process.)
YES NO IF YES, DATE FILED:
HAVE YOU REQUESTED FMLA, CFRA, PDL, OR OTHER LEAVE IN CONNECTION WITH THE ABOVE DESCRIBED
DISABILITY?
YES NO IF YES, PLEASE SPECIFY WHAT YOU REQUESTED AND WHEN:
I CERTIFY THAT I HAVE A DISABILITY THAT REQUIRES REASONABLE ACCOMMODATION, WHICH WILL BE MET BY THE
ACCOMMODATION(S) LISTED ABOVE.
SIGNATURE OF EMPLOYEE DATE
SECTION A: TO BE COMPLETED BY EMPLOYEE
NAME OF EMPLOYEE
CLASSIFICATION/JOB TITLE
WORK LOCATION/SUPERVISOR
WORK TELEPHONE NUMBER/EMAIL
ACCOMMODATION(S) REQUESTED (Be as specific as possible, for example adaptive equipment, reader, interpreter, training,
schedule change,
etc.):
REASON FOR REQUEST (Please do not disclose your diagnosis; explain your disability-related limitations and how this accommodation
will help you do your job
.)
IS YOUR LIMITATION:
Permanent
Temporary
Unknown
ANTICIPATED RECOVERY DATE (if any)
✔
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2
SECTION B:
CERTIFICATION FROM PHYSICIAN/HEALTH CARE PROVIDER:
When an employee’s disability or need for accommodation is not apparent or known to the employer, the
employer m
ay request a certification from a health care provider verifying that an accommodation is necessary
.
The
employer should provide the employee with a copy of a job duty statement to share with the health care
provider.
For completion by the health care provider: please provide a letter or verification addressing the following:
1. Verification that the employee has a disability (but not the diagnosis).
2. Description of how the employee’s limitations impair the ability to perform the duties of the job and
indication of whether these limitations are temporary or permanent.
a. If temporary, state when they are expected to end.
3. Recommendation of specific reasonable accommodation(s).
(Note: Use the space below or attach a letter or
verification, which will be kept confidential. Employers must
generally retain medical certifications and related documents separately from usual personnel files
.)
DATE ACCOMMODATION TO END OR CONTINUOUS
SIGNATURE OF HEALTH CARE PROVIDER
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3
SECTION C: INTERACTIVE PROCESS DISCUSSION TO BE COMPLETED BY EMPLOYER
1. Document all interactive discussions with employee, including dates of the discussions, employee’s specific
request(s), names of all persons present, and what was discussed. Use additional pages if required.
Date Discussion Notes
2. List all potential reasonable accommodations identified in the interactive discussions and the strengths
and weaknesses for each as a potential reasonable accommodation.
3. State your recommended reasonable accommodation and the rationale for your recommendation.
4
SECTION D: TO BE COMPLETED BY EMPLOYER
LIST SPECIFIC ACCOMMODATION(S) TO BE PROVIDED:
For each accommodation requested by the employee that you deny, explain the reason for the denial:
(may check more than one box, use additional pages if needed)
Accommodation Ineffective
Accommodation Would Cause Undue Hardship. Identify Hardship:
Medical Documentation Inadequate
Accommodation Would Require Removal of an Essential Job Function. Identify Function:
Accommodation Would Require Lowering of Performance or Production Standard. Identify
Standard:
No Alternative Vacant Position Available. Positions
Considered:
Employee Rejected Alternative Accommodation. Identify Accommodation Offered and Reason for Employee’s
Rejection:
Other (Please identify)
Further Explanation/Comments
:
______________ __________________________________________________
Date
Signature
ACKNOWLEDGEMENT OF RECEIPT OF
REASONABLE
ACCOMMODATION
REQUEST
DATES
DATE
ACCOMMODATION TO BEGIN
DATE
ACCOMMODATION TO END
DATE EQUIPMENT
ORDERED IF NEEDED AND BY WHOM
DATE EQUIPMENT WAS
RECEIVED BY EMPLOYEE
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5
SECTION E: TO BE COMPLETED BY EMPLOYER FOLLOWING IMPLEMENTATION OF THE
ACCOMMODATION(S)
The employer should check in periodically with the employee to ensure that the accommodation is effective. If the
accommodation is not effective, there is a duty to reengage in the interactive process.
Document all interactive discussions with employee, including dates of the discussions, names of all persons
present,
what was discussed, and next steps if needed. Use additional pages if needed.
Date Discussion Notes
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REQUEST FOR REASONABLE ACCOMMODATION-CONFIDENTIAL (California)

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Completed 16 June 2021

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