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Employee Request for Disability-Related Reasonable Accommodation
The College at Brockport is dedicated to providing effective, reasonable accommodation for individuals with
disabilities. To identify and implement such accommodation, the College engages in an “interactive process,” in
which the College and individuals with disabilities who request accommodations work together to reach an
appropriate outcome. The Affirmative Action Officer is responsible for working with qualified individuals with
disabilities to arrange changes in the work environment or procedures which enable an individual with
disabilities to experience equal employment opportunities.
Process
1. Employee completes the Employee Request for Disability-Related Reasonable Accommodation Form
and submits to the Affirmative Action Officer.
2. Employee provides their doctor with the Health Care Provider Information for Reasonable
Accommodation Request Form and instructs the doctor to submit completed form to the Affirmative
Action Officer.
3. Affirmative Action Officer:
Receives and reviews the employee request form and health care provider form.
Will notify the employee if a review of the request and of supporting documentation is
inconclusive, or if it is determined that medical documentation is inadequate or otherwise
problematic. The Affirmative Action Officer will specify to the employee why the
documentation is unacceptable, and the employee will be asked to submit additional
supporting documentation.
Contacts the employee’s manager and/or other Human Resources representatives as
necessary.
4. If, based on the review, the Affirmative Action Officer determines that the employee is entitled to an
accommodation and that the proposed accommodation is reasonable as defined by the Americans with
Disabilities Act (ADA), the Affirmative Action Officer will consult with the employee’s supervisor about
appropriate methods of implementing the requested accommodation or some variation thereof.
5. The Affirmative Action Officer will provide the employee and their manager written notification of the
approval or denial of the request for disability-related accommodation.
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APPEAL PROCESS
If the employee does not agree with the decision of the Affirmative Action Officer due to either:
a. Being denied the accommodation of; or,
b. Disagreement on the recommended accommodation(s) and an agreement cannot be
reached, the employee may initiate a formal appeal. The appropriate steps are:
An appeal must be submitted in writing to the Assistant Vice President for Human
Resources, The College at Brockport, 409 Allen Administrative Building, 350 New
Campus Drive, Brockport, NY 14420. The appeal must set forth the specific action
disputed and the specific accommodation sought by the employee. The Assistant
Vice President for Human Resources will notify the Affirmative Action Officer and
obtain a copy of the employees file, including the documentation of the disability
and the need for accommodation(s), if any, recommended by the evaluator and the
Affirmative Action Officer.
The Assistant Vice President for Human Resources will convene a meeting with the
employee and the Affirmative Action Officer within 2 weeks of receiving the written
appeal. The Assistant Vice President for Human Resources will make a decision on
the appeal after meeting with the employee and reviewing the file and
documentation.
The Assistant Vice President for Human Resources has the authority to make the
final determination regarding accommodation.
Disability Accommodation Resources
Questions or concerns regarding policy or services should be directed to:
Tammy Gouger
Affirmative Action Officer
409 Allen Administration Building
350 New Campus Drive
Brockport, NY 14420
585-395-2442
tgouger@brockport.edu
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Definitions
The following definitions are based on the New York Human Rights Law. Unlike both the Americans
with Disabilities Act (ADA) and the Rehabilitation Act of 1973, the New York Human Rights Law
protects all individuals with physical, mental or medical impairments that either impede normal bodily
function or are demonstrable by medically accepted diagnostic technique. The protection of the
federal statutes is limited to those impairments that substantially limit one or more major life
activities.
Essential Job Functions: Essential functions are those fundamental to the position; A function is
essential if not performing that function would fundamentally change the job occupation for which
the position exists.
Person With A Disability: a person who has “a physical, mental, or medical impairment,” who, upon
provision of a reasonable accommodation if needed, is able to perform in a reasonable manner, the
activities involved in the job or occupation sought or held. Individuals with a disability also include
persons who have a record or history of impairment, even if they do not currently have impairment.
These individuals are protected from bias, but only current impairments need to be reasonably
accommodated. Persons who have a condition regarded by others as an impairment, or who are
incorrectly perceived as having an impairment, are also protected from discrimination. However, only
actual impairments need to be reasonably accommodated. Physical, Mental or Medical Impairment:
any impairment “resulting from anatomical, physiological, genetic, or neurological conditions which
prevents the exercise of a normal bodily function or is demonstrable by medically accepted clinical or
laboratory diagnostic techniques.”
Qualified Person with a Disability: a person with a disability who, as defined below, can reasonably
perform the activities involved in the job, and who satisfies the requisite skill, experience, education
and other job-related requirements of the position which the individual holds or desires.
Reasonable Accommodation: The New York Human Rights Law, the Rehabilitation Act of 1973, and
the Americans with Disabilities Act (ADA) of 1990 require that employers provide reasonable
accommodation to the known physical or mental limitations of otherwise qualified applicants or
employees with disabilities, unless it can be demonstrated that providing such accommodations would
result in undue financial or operational hardships.
Reasonable accommodation refers to the modifications or adjustments to a job application process
which enables a qualified individual with a disability to be considered for the position sought and to
modifications or adjustments to the work environment or the manner in which a job is performed. An
accommodation is reasonable if it removes or mitigates the barriers to performance caused by the
individual’s impairment, and does not cause undue hardship to the employer.
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Reasonable Performance: The Human Rights Law protects from discrimination those who can
reasonably perform the job, with reasonable accommodation, if needed, despite the person’s
impairment. Reasonable performance is not perfect performance or performance unaffected by the
disability, but reasonable job performance reasonably meeting the employer’s needs to achieve its
business goals. Ability to reasonably perform the “activities involved in the job or occupation” means
the ability, with or without accommodation, to satisfactorily perform the essential functions of the job
as established by the employer. The employer’s judgment, as to what is minimally acceptable
performance will prevail, so long as standards for performance are applied equally to all employees in
the same position.
Undue Hardship: this means significant difficulty or expense to the employer. In determining whether
an accommodation would result in undue hardship, any relevant factor may be considered.
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____
_________________________________________________ ___________________________
EMPLOYEE REQUEST FORM FOR DISABILITY-RELATED REASONABLE ACCOMMODATION
Instructions: To request accommodation in the workplace due to a disability, please submit the completed
request form to the Affirmative Action Officer. In addition, the Health Care Provider Information for
Reasonable Accommodation Request Form must be completed by a qualified healthcare professional who has
made the diagnosis of your condition and/or is currently providing treatment of the condition.
Name________________________________________Email___________________________________
Budget Title___________________________________Campus Title_____________________________
Division______________________________________Work Location_____________________________
Manager’s name_______________________________________________________________________
Work Phone __________________________________Home Phone _____________________________
Describe how your disability affects your ability to perform the essential job functions of your position:
I am requesting the following accommodation(s):
Describe how this requested accommodation(s) is necessary to perform the essential job functions of your
position:
E
mployee Signature Date
I understand that all information provided to the Affirmative Action Officer is kept confidential and will only
be shared with individuals directly involved in the review of the accommodation(s) request.
Return completed form to: The College at Brockport, Tammy Gouger, Affirmative Action Officer, 409
Allen Administration Building, 350 New Campus Drive, Brockport, NY 14420.
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HEALTH CARE PROVIDER INFORMATION FOR REASONABLE ACCOMMODATION REQUEST FORM
Employee Name: ____________
A.
Questions to help determine whether an employee has a disability.
For reasonable accommodation under the Americans Disability Act (ADA), an employee has a
disability if they have an impairment that substantially limits one or more major life activities or
a record of such impairment. The following questions may help determine whether an
employee has a disability:
1. Does the employee have a physical or mental impairment? Yes No
a. If yes, what is the impairment? (Please be specific)
b. Is the impairment(s) temporary? Yes No
c. If the above is yes, what is the anticipated duration?
Answer the following question based on what limitations the employee has when their
condition is in an active state and what limitations the employee would have if no mitigating
measures were used.
Mitigating measures include things such as medication, medical supplies, equipment, hearing
aids, mobility devices, the use of assistive technology, reasonable accommodations or auxiliary
aids or services, prosthetics, learned behavioral or adaptive neurological modifications,
psychotherapy, behavioral therapy, and physical therapy. Mitigating measures do not include
ordinary eyeglasses or contact lenses.
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1. Does the impairment substantially limit a major life activity? Yes____No
Note: The impairment does not need to significantly or severely restrict the individual to
meet this standard. It may be useful in appropriate cases to consider the condition under
which the individual performs the major life activity; the manner in which the individual
performs the major life activity; and/or the duration of time it takes the individual to
perform the major life activity, or for which the individual can perform the major life
activity.
a. If yes, what major life activity(s) is/are affected?
Bending
Hearing
Reaching
Breathing
Interacting WithOthers
Reading
Caring for Self
Learning
Seeing
Concentrating
Lifting
Sitting
Eating
Performing Manual Tasks
Sleeping
Speaking
Standing
Thinking
Walking
Working
Other
b. If yes, what major bodily functions is/are affected?
Bladder
Bowel
Brain
Cardiovascular
Circulatory
Lymphatic
Musculoskeletal
Neurological
Normal Cell Growth
Operation of an Organ
Reproductive
Respiratory
Special Sense Organs &Skin
Other: (describe)
B.
Questions to help determine whether an accommodation is needed. An employee with
a disability is entitled to an accommodation only when the accommodation is needed
because of the disability. Accommodation ideas and suggestions are always welcome
and can be helpful however, employers do get to choose the effective
accommodation that will be provided for an employee, as outlined by the Equal
Employment Opportunity Commission (EEOC.) To assist us in determining the most
appropriate and effective accommodations, the employer needs to know what
specific symptoms and functional limitations are creating barriers for the employee.
The following questions may help determine whether the requested accommodation
is needed because of the disability. Please answer the following with as much detail as
possible.
1. What limitation(s) is interfering with job performance or accessing a benefit of
employment? (What is getting in the way of the employee from doing their job?)
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2. What specific job function(s) or benefits of employment is the employee having
trouble performing or accessing because of the limitations?
3. How does the employee’s limitation(s) interfere with their ability to perform
the job function(s) or access benefit of employment?
C.
Questions to help determine effective accommodation options: If an employee
has a disability and needs an accommodation because of the disability, the
employer must provide a reasonable accommodation, unless the accommodation
poses an undue hardship. The following questions mayhelp determine effective
accommodations.
1. Do you have any suggestions regarding possible accommodations to improve job
performance? Yes ___ No___
a. If so, what are they?
2. How would your suggested accommodations improve the employee’s job performance?
D.
Other Questions and Comments.
Medical Professional’s Signature Date
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
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 reproductiveservices.
Please return this form to Tammy Gouger, Affirmative Action Officer, The College at Brockport, 409
Allen Administration Building, 350 New Campus Drive, Brockport, NY 14420 or by fax: 585-395-5275
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