Request for Reasonable Accommodation – Southam and Associates

A disabled person is defined by the Americans with Disabilities Act (ADA) as:

1. An individual with a physical or mental impairment that substantially limits one or more major life activities.

2. An individual with a record of a substantially limiting impairment.

3. An individual who is perceived to have such an impairment.

Those who believe to be covered by the Act and who wish to request accommodation may do so with HR or with a member of management. Please note, any information provided below and any discussions in the interactive process will be kept confidential and to business necessity to the extent possible. All information will be used in compliance with applicable laws.

Date of Request: *

Employee's Name *

First

Last

Person filling out this form *

Department *

Supervisor: *

Describe the nature, extent, and duration of your disability: *

Describe the accommodations you believe are needed to enable you to perform the essential functions of this job. Be as specific as possible, for example equipment changes, physical restrictions, schedule, training, interpreter, etc.: *

Supporting Documentation: Attach any supporting documentation that may be helpful in evaluating this request for accommodation.

Click or drag files to this area to upload. You can upload up to 3 files.

By signing, I certify that:
• I authorize the release of information regarding my disability to management as deemed necessary by HR or management to facilitate this request for accommodation.
• The information provided is true and accurate.
• I understand that any misrepresentation may result in a denial and potential disciplinary action.

Employee to sign printed copy of form for HR Department.

Employee's Signature: ____________________________________________________________

Date Signed: ________________