??ࡱ?>?? ????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????O ??1?bjbjh8h8 ?? RWi RWi? ?????????N N ??TTT$????xxxP???<xEd??h@@@@H??Hl0I8?b?b?b?b?b?b?b$'g??i?c?ThI G?HhIhIc??@@?(?cQQQhIR?R@T@?bQhI?bQQ?]|2"?^@????`??????????I??]?bd0Ed?]??j`J?j$?^?jT?^XhIhIQhIhIhIhIhIccfN?hIhIhIEdhIhIhIhI?????????????????????????????????????????????????????????????????????jhIhIhIhIhIhIhIhIhIN X ?: The American Disabilities Act (ADA) Coordinator assists applicants, employees, hiring officials, supervisors, and managers in determining the essential functions of jobs and obtaining documentation of functional abilities and limitations, unless the limitations are obvious; researching and considering possible accommodations; and selecting an effective accommodation. The ADA Coordinator may collaborate with Student Access Center to ensure that students receive academic accommodations and with program sponsors to ensure that programs and activities are accessible.PART I: REASONABLE ACCOMMODATION REQUEST FORMThis form is to be completed by Applicant/Employee (sometimes referred to as ?requestor?), or Supervisor/Administrator to assist in a reasonable accommodation request. The form should be submitted to the Human Resources, Employee Relations & Engagement, 111 Dykstra Hall, 1628 Claflin Rd, 785.532.6277 TRS: 711. Use of this form is not required to initiate a request. Requestors? use of this form is strongly encouraged, as it is provided as a tool to aid in the reasonable accommodation process. If the requestor does not complete the form, the ADA Coordinator may complete the form on the requestor?s behalf after having been notified of a request.PART II: HEALTH CARE PROVIDER FORMIf a requestor?s disability and/or need for accommodation are not obvious or already known (e.g., from a previous request) to the University, the University is entitled to ask for and receive medical information showing that the requestor has a covered disability that requires accommodation. In those circumstances this form is to be completed by the appropriate health care professional. It is the responsibility of the requestor to see that this form is completed and submitted to Human Resources, Employee Relations & Engagement, 111 Dykstra Hall, 1628 Claflin Rd, 785.532.6277 TRS: 711. After receipt, and as part of processing the request (Part III), the ADA Coordinator will explain what additional information is needed from the professional, if any. The requestor should then ask his/her health care professional for the missing information, and the requestor shall provide it to the ADA Coordinator.PART III: PROCESSING THE REQUESTThe ADA Coordinator shall contact the Applicant/Employee and the Supervisor/Administrator or other University official. If the Supervisor/Administrator receives the request, they will forward the request to the ADA Coordinator. The ADA Coordinator will work with the Supervisor/Administrator to gather relevant information necessary to respond to a request and to assess whether a particular accommodation will be effective. The individual requesting the accommodation must communicate with the Supervisor/Administrator and the ADA Coordinator about the request, the nature of the problem generating the request, how a disability is prompting a need for an accommodation, and alternative accommodations that may be effective in meeting the individual?s needs. The ADA Coordinator also may require that the requestor undergo an independent medical examination. The ADA Coordinator and Supervisor/Administrator shall maintain confidentiality and only share information on a need-to-know basis or as otherwise permitted by applicable law. The University will process requests and, where appropriate, provide accommodations in a reasonable timeframe. REASONABLE ACCOMMODATION REQUEST FORMPART I: To be completed by Applicant/Employee or Supervisor/Administrator to aid in requesting a reasonable accommodation in the workplaceA. GENERAL INFORMATIONApplicant/Employee InformationSupervisor InformationApplicant/ Employee s Name FORMTEXT      Supervisor s Name FORMTEXT      Title  FORMTEXT      Phone (###-###-####) FORMTEXT      Department FORMTEXT      E-mail FORMTEXT      Campus/Location FORMTEXT      Phone (###-###-####) FORMTEXT      E-mail FORMTEXT      B. QUESTIONS TO CLARIFY ACCOMMODATION REQUEST1. Briefly, describe the disability/medical impairments for which you are requesting an accommodation. FORMTEXT      2. What function of your job are you having difficulty with? FORMTEXT      3. What specific accommodation are you requesting? FORMTEXT      4. What other accommodations would be responsive to your request? FORMTEXT      5. Check the appropriate box below (may check more than one box) and explain how the reasonable accommodation will assist you in: FORMCHECKBOX  Application process FORMCHECKBOX  Performing job functions or accessing the work environment FORMCHECKBOX  Accessing a benefit or privilege of employment (e.g., attending training program or office event) Explanation FORMTEXT      6. Have you had any accommodations in the past for this same limitation? FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, what were they and how effective were they? FORMTEXT      7. If you sought assistance from your supervisor, or from any other person, please provide the date and the result.C. OTHER.Please provide any additional information that might be useful in processing your accommodation request: FORMTEXT      FMLA Notice: If you request leave for a serious health condition, you must also consult with your department Human Capital Liaison and comply with the department?s usual and customary leave notice and procedures for requesting FMLA leave. See PPM Ch. 4860.040.I affirm that all statements made above are true to the best of my knowledge and belief.Applicant/Employee SignatureDate PART II: HEALTH CARE PROVIDER FORM TO BE COMPLETED BY APPLICANT/EMPLOYEE:Applicant/Employee?s Name FORMTEXT      Provide a brief description of the disability/medical impairment for which you are requesting an accommodation. FORMTEXT      MEDICAL DOCUMENTATIONTO BE COMPLETED BY A HEALTH CARE PROVIDER, SOCIAL WORKER, OR REHABILITATION COUNSELOR: Have you made a diagnosis that relates to this reasonable accommodation request? If yes, please state the diagnosis. FORMTEXT       What is the disability/impairment(s) of the applicant/employee in regard to the description above? FORMTEXT      Does the impairment substantially limit a major life activity compared to the general population, including but not limited to: walking, sleeping, hearing, or major bodily functions such as of the respiratory, immune, digestive, or other bodily system or functions? Please explain. FORMTEXT      Please explain the impact of the limitation/impairment on major life activities listed above. FORMTEXT      What accommodations do you believe are necessary to enable the applicant/empl '*+iu ? ? ? ? ? ?  A B C I q r ???ɽ?򢗏??????|?|?t??l?]Q]h?FCJOJQJaJh G?h G?CJOJQJaJh?JSOJQJh??OJQJh?,?OJQJhV?h?&?OJQJhV?OJQJhV?hV?OJQJh??h?p?CJOJQJaJh??CJOJQJaJhT2FCJOJQJaJ jh?jbh?"WUmHnHuh?]WCJOJQJaJh?JSCJOJQJaJjh?"WUmHnHuB C r ? ? #???QSTVWYZ???????????????????????? $???]???a$gdoT>$a$gd?p?$a$gd?@?gdV?gd?JSgd G?r u ? ? ? ? ? ? ? ?     > ? 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FORMTEXT      What is the anticipated duration and frequency of this medical limitation/impairment? FORMTEXT      Is it your opinion that your patient will be able to perform the essential function of his/her position safely and effectively if the reasonable accommodation he/she has requested is provided? FORMCHECKBOX  Yes FORMCHECKBOX  NoIf no, explain. FORMTEXT      GINA Notice: 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 are asking 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 of an embryo lawfully held by an individual or family member receiving assistive reproductive services. CERTIFICATIONHealth Care Practitioner, Social Worker, Rehabilitation Counselor Name FORMTEXT      Office Address FORMTEXT      SignatureDate Rev. 11/23Applicant/Employee should return this form to:Human Resources, Employee Relations & Engagement,111 Dykstra Hall, 1628 Claflin Rd, Phone:785-532-6277, TRS:711 Fax:785-532-6095InstructionsWe have been requested to consider a reasonable accommodation for the individual named above. An accommodation is a logical adjustment made to a job and/or the work environment that enables a qualified employee with a disability to successfully perform the essential duties or functions of the position. 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