ࡱ> BDAq` bjbjqPqP .7::    8P d $-( III$Uhx]'"I]] GGG]X  G]GG JO X0-5 554IvTGDWIIIXIII-]]]]    Reasonable Accommodation Request Title I of the Americans with Disabilities Act of 1990 (the ADA) requires ϳԹ of York County District Three to provide reasonable accommodation to qualified individuals with disabilities, unless to do so would cause undue hardship. Please complete the following in order to verify the existence of an ADA disability and the need for a reasonable accommodation. Employee Name: Date:Location: Grade, Subject, or Assignment: If your disability and need for accommodation are not obvious, the district will require documentation acceptable to the district from a physician or other healthcare professional to validate your disability under the qualifications of ADA and to establish the necessary reasonable accommodation. Have you already provided this documentation? YES ( NO ( If yes, at what date and from which Physician? ____________________________________________ If no, and your disability is not observable, please attach documentation from a Physician or other healthcare professional establishing you have a qualified ADA disability and the necessity and description of the type of suggested accommodation. What is your specific functional limitation in regards to the disability in question? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ What is the workplace problem or barrier that you feel could be removed with a reasonable accommodation? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Do you have a suggestion for a reasonable accommodation? If so, please describe: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Personnel Office Date received: ____________________ Signature: ___________________________________________     ADA 01142009  Iz * , . 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