Fill and Sign the Reasonable Accommodation Form

CONFIDENTIAL Reasonable Accommodation Request Form The purpose of this form is to assist { Insert Name of Company } in determining whether, or to what extent, a reasonable accommodation 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 be treated confidentially. SECTION I: Employee: To be completed by employee requesting accommodation . Employee:       Telephone:       Job Title:       Request Date:       I give { Insert Name of Company } permission 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 accordance with confidentiality requirements of those statutes. I further understand that I may be required to complete and sign the attached release of information giving { Insert Name of Company }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 and potential accommodations.       Date Employee's signature Please answer the following questions to assist us in understanding the basis and nature of your request for an accommodation (attach additional sheets if necessary). A. What are the limitations caused by your condition(s) that you are currently experiencing?                               B. Given your limitations, what parts of your assigned job duties are impeded by your condition?                               C. In order to get us thinking about an effective accommodation, tell us what accommodation/accommodations you envision to make it possible for you to continue to do the job well.                               SECTION II: Employer: To be completed by employing department/unit . Has the employee signed a Reasonable Accommodation Request Form (Section I)? Yes No If no, request signature. (Copy to be given to the employee.) Has an Essential Job Function Analysis been completed? Yes No If no, complete attached Job Function Analysis Form. If you need assistance in analyzing the essential functions of the job in question, please contact Human Resources. Send a copy of the signed Reasonable Accommodation Request Form (Section I), completed Essential Job Function Analysis Form, and employee's current job description to Human Resources. SECTION III: To be completed by Human Resources 1. Send a copy of: 1. The signed Health Care Professional Release Form 2. Essential Job Function Analysis Form 3. Job description 4. Cover letter to the health care professional(s) (where applicable). 2. After receiving documentation from the health care professional(s) answer the following: Has a health care professional documented that the employee has a physical or mental impairment that substantially limits the employee's ability to perform essential job functions? Yes No Other If yes or other, Recommendations:                               Accommodation Request is: Approved       Denied       Other       List specific reasonable accommodation(s) approved or provide the reason that a request was denied:                               Approvals: Employee: Date:       Supervisor: Date:       Human Resources: Date: