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Reasonable Accommodation - Reasonable_Accommodation

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HR / Employee and Labor Relations
620 West Lexington Street, 3rd Floor
Baltimore, MD 21201
410 706 7302
REVISED'04/23/2018'-'UNIVERSITY'OF'MARYLAND,'BALTIMORE!
-CONFIDENTIAL- !
REQUEST'FOR'REASONABLE'ACCOMMODATION'FORM'–'EMPLOYEE!
The!purpose!of!this!form!is!to!assist!the!University!in!determining!whether,!or!to!
what!extent,!a!reasonable!accommo datio n!is!required!for!an!employee!with!a!
disability!to!perform!one!or!more!essential!functions!of!their!job!safely!and!
effectively.! This%form%must%be%filed%separately%from
%the%employee’s%personnel%file%and
%
will%be%kept%in%the%Human Resources / Employee and Labor Relations (HR/ELR)%unit.!
University/Administrative!Area:
!
Department/Unit:!
SECTION'I:! To!be!completed!by!employee!requesting!accommodation.!
Name:
!
Department:
!
Address:!
Phone:!
Cell:!
Email:!
Job!Title:! Request!Date:!
Department!Head/Supervisor:!
Location:!
Phone:!
Note:! ADA%does%not%require%that%a%specific%or%requested%accommodation%be%granted%but%rather%
that%an%appropriate,%reasonable%accommodation%be%made%to%a%qualified%individual%with%a
%
disabili ty.% The%University%will%make%every%effort%to%reasonably%accommodate%an%employee%who
%
has%a%disability%if%that%accommodation%allows%the%employee%to%fully%carry%out%the%duties%of%
his/her% position. % Every%effort%will%be%made%to%involve%the%individual%with%a%disability%in%
identifyin g %and%imple m e n tin g %reasonable%accomm odations.!
I!am!hereby!requesting!a!reasonable!accommodation!due!to!my!disability.! I!grant!
permission!to!HR/ELR!and!individuals!identified!by!the!unit!as!necessary
!
participants!in!the!decision-making!process!to!explore!coverage!and!reasonable!
accommodations!under! the!Americans! with!Disabilities! Act.! I!understand!that!all!
information!obtained!during!this!process!will!be!maintained!and!used!in!acco r dance
!
with!ADA!confidentiality!requirements.!
PRINT
2!
I!further!understand!that!I!am!required!to!complete!and!sign!the!attached!release!of
!
information!form!(Authorization%for%Disclosure%of%Health%Information)!g iving!HR/
ELR!permission!to!consult!with!my!health!care!professional(s) !in!order!to!
determine!that!I!am!a!qualified!employee!with!a!disability!and!to!seek!guidance!as!
to!any!functional!limitations!based!on!my!disability.!
Employee’s!signature! Date!
SECTION'II:' To!be!completed!by!employing!department/unit.!
Has!the!employee!signed!a!Request!for!Reasonable!Accommodation!Form!(Section!I)?!
YES!
NO!
If%no,%request% signature.%(Copy%to%be%given%to%the%employee.)!
Signature!of!Employing!Dept.!/Unit!Supervisor!or!Liaison! Date!
Employing'Department/Unit:!
Send!a!copy!of!the!employee’s!current!job!description!to!HR/ELR!at!
620!W.!Lexington!Street,!3
rd!
Floor,! Baltimore,!MD! 21201.! !
You! may!email!the!job!description!to!Sheila Blackshear. !
If!you!have
!
any!questions,!please!call!410-706-7302.!
Employee:!
Send!a!copy!of!the!entire!signed!Request!for!Reasonable!Accommodation!Form
!
(Section!I,!II!and!IIA) !to!HR/ELR!at!620!W.!Lexington!Street,!3
rd!
Floor,! Baltimore,!
MD! 21201.! !
You!may!email!the!document!to!Sheila Blackshear.! !
If!you!have!any!questions,!please!call!410
-
706-7302.!
Section'IIA:'May!contain!personal!medical!information.! Please!DO!NOT!SHARE!with!
unauthorized!personnel,!including!your!employing!department!or!unit.!
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3!
REQUEST'FOR'REASONABLE'ACCOMMODATION'FORM'–'EMPLOYEE'(CONT’D)!
Name:!
SECTION'IIA:' To!be!completed!by!employee!requesting!accommo dation.!
The%Genetic%Nondiscrimination%Act%of%2008%(GINA)%prohibits%employers%and%other%
entities%covered%by%GINA%Title%II%from%requesting,%or%requiring,%genetic%information%of%
an%individual%or%family%member%of%the%individual,%except%as%specifically%allowed%by%this%
law.!
To%comply%with%this%law,%we%are%asking%that%you%not%provide%any%genetic%information%
when%responding%to%this%request%for%medical%information.%“Genetic%information,”%as
%
defined%by%GINA,%includes%an%individual’s%family%medical%history,%the%results%of%an%
individual’s%or%family%member’s%genetic%tests,%the%fact%that%an%individual%or%an%
individual’s%family%member%sought%or%received%genetic%services,%and%genetic%
information%of%a%fetus%carried%by%an%individual%or%an%individual’s%family%member%or%an%
embryo%lawfully%held%by%an%individual%or%family%member%receiving%assistive
%
reproductive%services.!
Please!answer!the!following!questions!to!ass ist!us!in!understanding!the!basis!and!
nature!of!your!request!for!an!accommodation!(attach!additional!sheets!if!necessary).!
A. Please!state!the!nature!of!your!disability!and,!as!necessary,!attach!documentation
from!your!qualified!health!care!provider!to!verify!your!disability.
B. Wh
at!are!the!limitations!caused!by!your!condition(s)!that!you!are!currently
experiencing?! Identify!the!essential!functions!affected!and!be!specific!about!how
the!medical!condit
ion!impairs!your!ability!in!each!instance.
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4!
C. Given!your!limitations,!what!parts!of!your!assigned!job!duties!are!impeded!by
your!condit ion?
D. Describ
e!the!accommodation(s)!you!are!requesting?
E. Explain
!how!the!accommodation(s)!you!are!requesting!will!enable!you!to!perform
the!essential!functions!of!your!job?
F. Wi
ll!you!be!able!to!per form!all!the!essential!functions!of!your!job!if!you!receive!the
requested!acco
mmodations?! If!not,!describe!the!functions!you!will!not!be!able!to
perform.
PRINT
5!
G. Do!you!need!as sistance!to!identify!accommodation(s)!that!will!enable!you!to
perform!the!essential!functions!of!your!job?! If!you!do,!explain!what!type!of
assistance!you
!need.
H. Provide!any!information!or!suggestions!you!can!on!how!the!requested
accommodation(s)!can!be!provided.! If!known,!include!the!names,!address!and
telephone!numbers!of!vendors!and!model!number!and!approximate!cost!of! any
equipment!requested.
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Reasonable Accommodation - Reasonable_Accommodation

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Completed 25 February 2020

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