Lamar State College - Port Arthur
Reasonable Accommodation Request Form
Employee Name: _______________________ Job Title: ___________________________
Department: ___________________________ Employee ID: _______________________
I wish to request Reasonable Accommodation for the following impairment or disability as
defined by the Americans with Disabilities Act, 1990. Please state impairment or disability:
What specific accommodation(s) are you requesting? Please explain how the accommodation(s)
will assist you to perform your job?
I understand that Lamar State College - Port Arthur may require a confirming examination or a
doctor’s letter before my request is consider.
Examination or Doctor’s Letter Requested: ☐YES ☐NO
Document Received: ☐YES ☐NO
__________________________________ ______________________
Signature of Requesting Employee Date
☐
YES Approve Accommodation Request
☐ NO Disapprove Accommodation Request based on undue hardship for the reason:
________________________________________________________________________
__________________________________ ______________________
Manager’s/Chair’s Signature Date
☐
YES Approve Accommodation Request
☐ NO Disapprove Accommodation Request based on undue hardship for the reason:
________________________________________________________________________
__________________________________ ______________________
Vice President’s Signature Date
