Reasonable Accommodation Request by 46883uyS

VIEWS: 17 PAGES: 6

									                                                                                 Human Resources

                                                                           Att: Employee Relations
                                                                             Phone: 502. 852.6536
                                                                                 FAX: 502.852.5665
CONFIDENTIAL
REASONABLE ACCOMMODATION REQUEST

Employee Name: ________________________________________________________________
                    First                     Middle              Last

Home Address: ________________________________________________________________


______________________________________________________________________________
       City                            State               Zip

Telephone: (      ) ____________________________ (            ) ____________________________
                        Home                                             Other
Employee identification number: ___________________ Today’s Date: ____________________
Department you are employed in: __________________________________________________


To request a reasonable accommodation at University of Louisville, an applicant or employee
should complete this form and provide written documentation by his/her physician(s) that
describes the disability and specific accommodation requested.

The Reasonable Accommodation Request form and Health Care Provider Statement(s) must be
sent to the Human Resources Department. This information will be kept confidential and
separate from the applicant’s employment file or the employee’s personnel file.

The purpose of this form is to assist university in determining whether or to what extent a
reasonable accommodation is required for an applicant or employee to perform the essential
functions of his or her job safely and effectively. If additional space is needed, please attach a
separate sheet of paper.

TO BE COMPLETED BY THE APPLICANT/EMPLOYEE

        1. Identify and describe the physical or mental disability, illness, condition or disease
           which is the basis for your request for reasonable accommodation(s):
           (**“Disability” includes a physical or mental impairment that substantially limits one
           or more major life activities: caring for oneself, performing manual tasks, walking,
           sitting, standing, lifting, reaching, seeing, hearing, breathing, learning, and working.)

            ____________________________________________________________________
            ____________________________________________________________________
            ____________________________________________________________________
            ____________________________________________________________________

                 ▪                      ▪
2. Identify and describe the essential function(s) of your position which you are
   unable to perform without reasonable accommodation(s):
   (**“Reasonable Accommodation” includes any modification to the job or work
   environment to enable an employee to perform the essential functions of the job in
   question.)

   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


3. Identify and describe the reasonable accommodation(s) you believe is (are)
   needed to enable you to perform the essential functions of your position properly
   and safely, including special equipment, changes in the physical layout of the job
   or other accommodations:

   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4. Identify and describe any special methods, skills, or procedures which would
   enable you to perform the essential functions of the position:

   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5. Identify and describe any equipment, aids, or services that you are willing to
   provide and utilize:

   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
        6. Identify the names and addresses of any and all health care providers who have
           information or documentation concerning your disability, illness, or disease and
           need for a reasonable accommodation by the university:

            1. Name: ___________________________________________________________

                Address: _________________________________________________________

                City: _________________________________ State: ________ Zip: __________

            2. Name: ___________________________________________________________


                Address: _________________________________________________________

                City: _________________________________ State: ________ Zip: __________

            3. Name: ___________________________________________________________


                Address: _________________________________________________________

                City: _________________________________ State: ________ Zip: __________

I hereby authorize the above-listed health care providers and any others who have treated me
to release to the university all medical records concerning the disability disclosed herein and
provide any opinions to the university concerning my ability to perform job-related functions
with or without reasonable accommodation. I also authorize disclosure and discussion as
necessary within the university to determine appropriate accommodations.

I certify that I have read and reviewed the job description for the position and/or been informed
of the essential functions of the job. I further certify that the foregoing statements are
complete, accurate and true to the best of my knowledge and I understand that a misstatement
or material omission of fact may be cause for dismissal.

I also understand the university may require me to undergo testing or evaluation by medical
personnel retained by the university for the purpose of establishing the existence and extent of
my disability, illness, condition or disease and my ability to perform job-related functions with or
without reasonable accommodation. I further understand that the university is not obligated to
provide any specific accommodation requested, but will evaluate such request in light of all
information available in making a determination of reasonable accommodation.

Employee Signature: _____________________________________Date: ___________________

**Note: Definitions are provided only as a guide for completing this form. Nothing in this form
is intended to alter the legal definition of these terms or impose obligations on the University
not required by law.
                                                                       Attn: Employee Relations
                                                                           Phone: 502.852.6536
                                                                              Fax: 502.852.5665
Health Care Provider
Disability Verification Form
 ______________________________________________________________________________
 ______________________________________________________________________________


INSTRUCTIONS: The employee indicated below has declared a disability and
requested a reasonable accommodation in the workplace under the provisions of the
Americans With Disabilities Act (ADA).
Employee Name: ________________________________________________________________
                    First                     Middle              Last
Home Address: _________________________________________________________________

______________________________________________________________________________
       City                            State               Zip

Job Title: _______________________________________________________________________

Department: ___________________________________________________________________

A facsimile or photocopy of this form will have the same force and effect as the original signed
copy.

This information should be submitted to the Human Resources Department with the
employee’s Reasonable Accommodation Request form. The information sought is job-
related and consistent with business necessity for the following reasons:
     to determine if the individual meets the ADA definition of “individual with a
        disability”;
     to determine if the individual is a qualified person under the ADA, meaning he or
        she can perform the essential functions of the job currently held, (or held before
        the injury or illness), with or without reasonable accommodation, and without
        posing a “direct threat” to health and safety of self or others that cannot be
        reduced or eliminated by reasonable accommodation; and
     to identify an effective reasonable accommodation that would enable the
        individual to perform essential job functions in the current (or previous) job, or
        in a currently vacant job for which the person is qualified (with or without
        accommodation).

Included is a copy of this individuals job related duties and responsibilities.
The responsibility of making employment decisions or deciding whether or not it is
possible to make a reasonable accommodation for a person with a disability lies with
officials of the University of Louisville.
The Employee has authorized this information to be released to the Human Resources
Department, University of Louisville.


       1. Please describe the employee’s current health condition/disability:

          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________


       2. Date condition/ disability commenced:     ________________________________

       3. Probable duration of condition/disability: _________________________________

       4. Does the employee’s medical condition result in a physical or mental impairment
          that substantially limits one or more “major life activities”? Yes ____ No ______
       If “yes”, please describe the functional limitations indicating which “major life
           activity” is affected:
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________


       5. Attached is a job description or information about the essential functions of the
          employee’s position. Please circle any items listed on the job description that the
          employee may not be able to perform based on the employee’s medical history
          and physical exam. Please circle your opinion by selecting one of the following
          options:

          a) should be able to perform the essential job functions without
             accommodation; or

          b) may not be able to perform the essential job functions circled on the
             attached job description and a reasonable accommodation is not
             feasible; or
            c) may not be able to perform the essential job functions circled on the
               attached job description; however, the following reasonable
               accommodation(s) should be considered to help the individual perform
               the essential functions of their job. Please list your recommendation for
               reasonable accommodation:
               ____________________________________________________________
                ____________________________________________________________
                ____________________________________________________________
                ___________________________________________________________


        6. (Optional) If necessary for the protection of the health and safety of this
           employee or others, please indicate special instructions for first-aid providers or
           supervisors:

            ____________________________________________________________________
            ____________________________________________________________________
            ____________________________________________________________________
            ____________________________________________________________________
            ____________________________________________________________________


Provider’s Name:
______________________________________________________________________________
Business Address:
______________________________________________________________________________


______________________________________________________________________________
             City                             State                      Zip


Type of Practice / Medical Specialty:
_____________________________________________________________________________


Telephone: (________) _________________________________________________________
Fax: (_______) ________________________________________________________________


__________________________________            ____________________________________
Signature of Health Care Provider               Date

								
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