A temporary accommodation provided for an employee before a permanent accommodation

							J-930-RA (3-11)                           ARIZONA DEPARTMENT OF ECONOMIC SECURITY
                                   REQUEST FOR REASONABLE ACCOMMODATION
                                                – CONFIDENTIAL –
An applicant, employee, his or her representative, or other authorized individual may complete questions 1-12 to request a reasonable
accommodation due to a disability. The information below, any documentation regarding the disability, and the request for
accommodation is strictly confidential. Any information obtained as a result of this request is not placed in your official personnel
file. (See instructions on reverse.)
(1) EMPLOYEE OR APPLICANT’S NAME (Last, First, M.I.)                                        (2) PHONE NO. (Include area code)           (3) SITE CODE


(4) OFFICE ADDRESS WHERE ACCOMMODATION IS NEEDED (No., Street, City, State, ZIP)


(5) DIVISION/ADMINISTRATION/OFFICE                                  (6) WORKING JOB TITLE AND OFFICIAL CLASSIFICATION


(7) NATURE OF DISABILITY


                                                                                                          (8) ADDITIONAL DOCUMENTATION ATTACHED

                                                                                                              Yes         No
(9) DESCRIBE THE FUNCTIONS OF YOUR JOB OR APPLICATION PROCESS THAT REQUIRE REASONABLE ACCOMMODATION




(10) DESCRIBE THE ACCOMMODATION YOU ARE REQUESTING (Special methods, skills or procedures, equipment, aids or services, and/or physical layout)




I believe I am a qualified individual with a disability covered under the Americans with Disabilities Act (ADA) or Rehabilitation Act
and request the Department of Economic Security (DES) to provide a reasonable accommodation. I authorize DES to:
   • contact me regarding the accommodation;
   • verify that I am eligible for the accommodation or any other effective accommodation under the ADA; and
   • notify the appropriate individuals in the Department to process this request.
I realize that at any time I may file a General Employee Grievance (IR-031) or file a complaint with the DES Office of Equal
Opportunity (OEO) for discrimination.
NOTE: Documentation of your disability may be required.
(11) DATE ORIGINATED           (12) APPLICANT, EMPLOYEE, HIS/HER REPRESENTATIVE OR AUTHORIZED INDIVIDUAL’S SIGNATURE


                               REMAINING PORTION TO BE COMPLETED BY DIVISION LIAISON
(13) DATE AND TIME             (14) NAME OF PERSON RECEIVING REQUEST (Please print clearly)                         (15) PHONE NO. (Include area code)


(16) IN PROCESSING THIS REQUEST FOR ACCOMMODATION, DID YOU: (Each item must be checked Yes, No, or N/A) [See instructions on reverse]

     Yes          No        N/A      a. Identify that the individual has a disability? (If No or N/A, please explain in Comments below)
     Yes          No        N/A      b. Define the essential functions of job? (If No or N/A, please explain in Comments below)
     Yes      Date                   c. Notify the employee in writing what accommodation is being provided (interim and permanent)?
     Yes      Date                   d. Provide follow-up with employee?
(17) INTERIM ACCOMMODATION PROVIDED                                                                                             (18) DATE


(19) PERMANENT ACCOMMODATION PROVIDED                                                                                           (20) DATE


(21) COMMENTS




(22) NAME OF PERSON WHO PROCESSED THIS REQUEST, AND WITNESS WHEN APPROPRIATE                                        (23) PHONE NO. (Include area code)



Distribution is as follows when a request is made: Original to Division Liaison, copy to Supervisor, copy to employee.
                                                   Completion Instructions for J-930
                               REQUEST FOR REASONABLE ACCOMMODATION
A. Purpose. For an employee, applicant or his/her responsible representative to request a reasonable accommodation.
B. Completion. Items not listed below are self-explanatory.
    7. NATURE OF DISABILITY. Describe the physical or mental impairment that substantially limits one or more of the
       employee’s life activities, such as walking, speaking, breathing, performing manual tasks, seeing, hearing, learning, caring
       for oneself, working, the record of having such an impairment or being regarded as having such an impairment.
    8. ADDITIONAL DOCUMENTATION ATTACHED. Medical documentation that verifies the identified disability and
       assists the employer in making an appropriate accommodation.
    9. DESCRIBE THE FUNCTIONS OF YOUR JOB OR APPLICATION PROCESS THAT REQUIRE REASONABLE
       ACCOMMODATION. The tasks that are part of the essential functions of the position for which accommodation is
       needed. For example, to make copies on a copy machine.
    10. DESCRIBE THE ACCOMMODATION YOU ARE REQUESTING. The accommodation that is required to perform the
        essential functions of the position, such as an accessible facility, equipment or devices. For example, a clear path of travel to
        make copies on a copy machine.
    11. DATE ORIGINATED. The date you completed the request portion of this form.
    13. DATE RECEIVED AND TIME. The supervisor or other designated individual, as authorized in the division’s procedures,
        documents the date and time they received the request for reasonable accommodation.
    14. NAME OF PERSON RECEIVING REQUEST. The employee’s supervisor or other designated individual as authorized
        in the division’s procedures.
    16. PROCESSING THIS REQUEST FOR ACCOMMODATION.
        The following guidance corresponds to questions 16a through 16d on the front of this form:
        a. If you determine that the employee does not have a disability as defined by the ADA, does not have a record of having
           such an impairment, or is not regarded as having an impairment, do not continue processing this form. Contact your
           Division ADA Liaison to confirm your determination, and provide what assistance may be necessary using your
           Division’s procedures. (Reference Title I, Technical Assistance Manual)
        b. This step is mandatory for providing an individual accommodation for an employee or applicant. (Reference the PDQ Job
           Description). If the request is to provide access to the facility, such as an automatic door opener at the main entrance to
           the office, this step may not be required.
        c. A copy of this form with block 17 or 19 filled in can be used to satisfy the requirement.
        d. After an appropriate evaluation period, confirm that the accommodation provided is operational.
    17. INTERIM ACCOMMODATION PROVIDED. A temporary accommodation provided for an employee before a
        permanent accommodation. (See the policy DES 1-01-06, Americans With Disabilities Act (ADA) Title I, Exhibit 5)
    19. PERMANENT ACCOMMODATION PROVIDED. Document the accommodation provided for the employee or
        applicant, the date the a accommodation is provided and provide a copy to the employee or applicant and the division liaison.
        If equipment is purchased, contact the division liaison. If extra space is needed for additional information, please
        document on a blank sheet and attach it.
    21. COMMENTS. Document necessary information pertaining to this request for future reference. If the employer denies an
        accommodation, this document must record the date and reason the employer has denied the referenced accommodation.
    22. A witness is recommended when a employee refuses an accommodation.


 Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
 Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008, the Department prohibits discrimination in
 admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
 genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in
 a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for
 people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any
 other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes
 to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability,
 please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further
 information about this policy, contact 602-364-3976; TTY/TDD Services: 7-1-1.