Reasonable Accommodation Request Form by eph19308



                Reasonable Accommodation Request Form
                      Western Kentucky University
Western Kentucky University seeks to reasonably accommodate individuals with disabilities as
provided under the Rehabilitation Act of 1973 and the Americans With Disabilities Act of 1990.
Reasonable workplace accommodations will be provided to applicants/employees except in
situations where a request may impose an undue burden on the institution. Reasonable
accommodations include any modifications to the job or work environment to enable an
employee to perform the essential functions of his/her job or to assist an applicant in the job
application process. For complete information on University policy please refer to HRP #80-
120, Accommodations for Employees With Disabilities.

As specified in federal regulations, a disabled person is defined as an individual (1) having a
physical or mental impairment that substantially limits a major life activity, (2) an individual
having a record of such impairment, or (3) an individual who is regarded as having such an
impairment. Major life activities include such things as caring for oneself, performing manual
tasks, walking, seeing, hearing, speaking, lifting, standing, concentrating and working. NOTE:
These definitions are provided only as a guide for completing this form. Nothing in this
form is intended to alter the legal definitions of these terms or impose obligations on the
University not required by law.

Form Instructions
The purpose of this form is to provide the necessary information to assist Western Kentucky
University in evaluating a reasonable accommodation request. Requests for accommodation will
only be considered upon presentation of this completed document, containing required
information and authorized signatures, to the Department of Human Resources. In compliance
with applicable laws and regulations, all documents pertaining to a disability accommodation
request will be placed in a separate confidential file and will only be accessible to the
employee/applicant, immediate supervisor (if necessary), or an appropriate Human Resource or
Equal Opportunity office representative or other appropriate University officials.

Section I
To Be Completed by the Employee/Applicant

1.      Identify and describe the physical or mental illness, condition or disease that is the basis
        for your request for reasonable accommodation.

2.      Identify and describe the essential functions of your job that you are unable to perform
        without a reasonable accommodation(s).

3.      Identify and describe the specific accommodating actions that you believe are necessary
        to enable you to perform essential job functions properly and safely (in the case of an
        applicant, to properly participate in the application process). This includes any job duty
        changes, usage of special equipment or changes in physical layout of the work
        environment. Please be as specific as possible.

Health Care Provider Information
Please provide below the names, addresses and phone numbers of health care providers who have
information or documentation concerning your disability, illness, condition or disease in
reference to your request for accommodation.

        Name                          Address                    Phone        Medical Specialty

Employee/Applicant Authorization
The personal health information provided in this document is being provided in order for Western
Kentucky University to evaluate my request for reasonable job accommodation. I certify that the
personal health information provided and my disability, as described herein, are accurate to the
best of my knowledge. I authorize my supervisor (if necessary) and appropriate Human Resource
or Equal Opportunity office representatives access and use of this information only for the
purpose intended.

I understand that the University is not obligated to provide any “specific” accommodation that I
might request, but will evaluate my request in light of the provided information and any
reasonable accommodation which may be appropriate when considering my essential job

I further understand that the University may request additional personal health or medical
information and may, at its discretion, require me to be evaluated by a health care professional(s)
retained by the University for the purpose of establishing the existence and extent of my

I authorize the health care providers indicated above to provide appropriate and relevant personal
health information (Section II) to Western Kentucky University (at One Big Red Way, WAB 42,
Bowling Green, KY 42101) for the purpose of evaluating my request for reasonable

_______________________________                            Date____________________
Full Name (Print)

_______________________________                            ________________________
Signature                                                  WKU ID

Section II
To Be Completed by Health Care Provider

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

2.      Please provide date condition/disability commenced. What is estimated duration of

3.      Does the employee’s condition/disability 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 and the “major life activity” affected.

4.      In reviewing the enclosed job description of the employee, please indicate your
        professional opinion as follows:

        ____The employee should be able to perform the essential job functions WITHOUT any

        ____The employee may not be able to perform the essential job functions and a
        reasonable accommodation is not advised/feasible.

     ____The employee should be able to perform the essential job functions WITH
     reasonable accommodations. Based on your professional opinion, please provide the
     specific accommodations recommended for consideration by the University.

5.   If appropriate, please indicate any actions necessary for the protection of the health and
     safety of the employee and other employees and any special instructions for first-aid
     providers and supervisors.

     _________________________________                          ________________________
     Health Care Provider (Print)                               Address

     _________________________________                          ________________________
     Area of Medical Specialty                                  Phone Number


                                    Return completed form to:

                              Department of Human Resources
                                Western Kentucky University
                               1906 College Heights Boulevard
                        Wetherby Administration Building – Room G-25
                               Bowling Green, KY 42101-1003
                                                                                   Revised 1/11/08


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