REQUEST FOR ACCOMMODATION OF DISABILITY

Employee’s Legal Name: _________________________

Position: _____________________

Principal/Supervisor: _______________________ Date:

___________________________

Building/Location_____________________________________________________________ Describe the disability or medical condition that requires an accommodation. Attach your doctor’s recommendation for specific accommodation(s) that will enable you to perform the essential duties of your position and any medical documentation regarding your condition that also supports your request.

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _______________________________________ Employee Signature

__________________________________ Date

********************************************************************************************* For District Use 1. Date Received: ___________________

____________________________________ Signature of Principal/Supervisor (Forward to Human Resources after Principal/Supervisor signature.)

2. Date Received by Human Resources: __________________________________________ 3. Additional Information Requested: ____________________________________________ __________________________________________________________________________ 4.

Date for additional information requested:_________ Date Received: _______________

6.

Date written decision for request issued: _____________

By: ___________________

ADA accommodation requests are handled in compliance with the School Board Nondiscrimination Policy 200

Revised 0614