4118.14  Form

4218.14

SECTION 504/ADA

   EMPLOYEE REQUEST FOR ACCOMMODATION

1.  Name of Employee: ___________________________ Title/Position:________________

2.  Eligibility Determination

Individuals considered eligible for protection from discrimination under Section 504/ADA are those who have a physical or mental impairment which substantially limits a major life activity; has a record of such impairment; or is recognized as having such an impairment.

A.  Please describe your mental or physical disability:

__________________________________________________________________

B.  Please describe the major life activity substantially limited by your disability:

__________________________________________________________________

C.  Please describe how your disability affects your ability to perform essential job functions:

__________________________________________________________________

__________________________________________________________________

D.  Please describe the specific accommodation(s) being requested:

__________________________________________________________________

__________________________________________________________________

E.  Have you attached medical documentation to support your request? [ ] Yes   [ ] No

F.  If "no", please provide the name and contact information for your treating physician:

Name: ___________________________________________________________

Address: _________________________________________________________

Telephone#: _______________________________________________________

3.  Authorization to Communicate with Medical Provider

I hereby authorize my employer, the ________ District to obtain, and for the medical provider listed above, to release confidential protected health information to the Director of Pupil Personnel Services for the limited purpose of determining any work related restrictions and/or accommodations which may be necessary in order to fulfill the essential function of my employment responsibilities.  Any information received by my employer pursuant to this authorization shall be subject to all applicable state and federal confidentiality laws governing further use and disclosure of such information.

____________________________________________________________________________________

Employee Signature                                                                                            Date

ONCE COMPLETED, THIS FORM, ALONG WITH SUPPORTING DOCUMENTATION SHOULD BE FORWARDED TO THE DIRECTOR OF PUPIL PERSONNEL SERVICES.