ADA - Form – Employee Request for Reasonable Accommodation

Name of Employee

First

Last

Current Position

Department

Work Schedule (Days & Hours)

Nature of Condition

Please describe any medical restrictions resulting from your condition.

Please describe how your condition and any resulting medical restrictions affect your ability to perform your job duties.

Please describe how you believe we can accommodate your condition.

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Please attach additional pages as necessary as well as any supporting medical documentation, and execute the attached medical release. However, the Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we ask that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Signature (please type name below):

Date:

ADA – Form – Employee Request for Reasonable Accommodation