HR Disability Brochure

HR DISABILITY BROCHURE

Purpose: This brochure explains the employer's disability accommodation policy, the interactive process, confidentiality protections, and an employee acknowledgment of receipt. The organization is committed to providing reasonable accommodations to qualified individuals with disabilities in accordance with applicable law while preserving operational integrity and avoiding undue hardship.

Personal Information

Position Information

Employment History (Most Recent)

Dates Employed: From to

Employment History (Prior)

Dates Employed: From to

Education

References (Professional)

Legal Disclosures

At-Will Employment: Unless governed by a separate written agreement signed by an authorized representative of the employer, employment with the organization is at-will. Either the employee or the employer may terminate the employment relationship at any time, with or without cause and with or without notice.

Equal Opportunity: The employer is an equal opportunity employer. Decisions regarding recruitment, hiring, promotion, compensation and other conditions of employment will be made without regard to race, color, religion, sex, national origin, age, disability, genetic information, or any other protected characteristic under applicable law.

Disability Policy — Substantive Provisions

Coverage and Definitions: A disability is any physical or mental impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment. This policy applies to qualified employees and applicants who meet the essential functions of a position with or without reasonable accommodation.

Requesting an Accommodation: An employee who needs a workplace accommodation should notify Human Resources or the immediate supervisor as soon as practicable. Requests may be made orally or in writing. Upon notice, the employer will engage in an individualized interactive process to identify possible reasonable accommodations.

Interactive Process and Timelines: The employer will respond to accommodation requests promptly and will make reasonable efforts to complete the interactive process within a commercially reasonable time frame, typically within 15 business days of receiving sufficient information. Timeframes may be extended where medical documentation is outstanding or additional assessment is required.

Medical Documentation and Confidentiality: Medical information obtained in support of an accommodation request will be kept confidential and maintained in files separate from the employee’s personnel file, except as required by law or where disclosure is necessary to evaluate or implement the accommodation. The employer may require reasonable documentation to substantiate the need for accommodation.

Reasonable Accommodation Standard and Undue Hardship: The employer will provide accommodations that are effective and reasonable. The employer is not required to provide an accommodation that would impose an undue hardship on business operations or fundamentally alter the nature of a job.

Non-Retaliation: The employer prohibits retaliation against any individual who requests an accommodation or participates in the interactive process. Any act of retaliation should be reported immediately to Human Resources for investigation and corrective action.

Request for Accommodation (Optional Form)

Date of Request:

Physical workplace modification

Schedule modification / leave

Assistive equipment / software

Reassignment to vacant position

Medical Release & Authorization

By checking the box below, I authorize the employer to request and obtain relevant medical information from my health care provider to evaluate my request for reasonable accommodation. I understand that medical information will be used solely for the purpose of evaluating and implementing accommodations and will be maintained confidentially in accordance with policy and law.

I authorize release of relevant medical information to the employer as described above.

Authorization to Contact Previous Employers & Background Checks

For purposes of verifying employment history and assessing accommodation-related work restrictions, I authorize the employer to contact prior employers and to obtain background checks where permitted by law. Such inquiries will be limited to job-related information and will comply with applicable privacy and employment laws.

I authorize contact with prior employers and background checks as described above.

Appeals and Dispute Resolution

If an accommodation request is denied in whole or in part, the employee may submit a written appeal to Human Resources. The appeal should state the reasons for contesting the decision and any additional information for consideration. Appeals will be reviewed by a designated HR representative and a final decision will be issued in writing.

Applicant Certification & Acknowledgment

I certify that the information provided on this form and in accompanying attachments is true, accurate and complete to the best of my knowledge. I understand that knowingly providing false information may lead to disciplinary action, up to and including termination of employment. I acknowledge receipt of the employer’s Disability Accommodation Policy and understand my rights and responsibilities under the policy.

I certify that the above statements are true and I acknowledge receipt of the Disability Brochure and Policy.

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