4218.14
SECTION 504/ADA
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.