DHS 3001 Accommodation Tracking Form

Accommodation Tracking Form

Supervisors, Human Resources staff or the ADA manager who receives a reasonable accommodation in employment request must complete this form. The agency’s goal is to make an initial offer of accommodation to the employee within 30 calendar days and to implement the accommodation within 60 calendar days from the date agency management is made aware of the need.

Employee information Date of request or triggering duty*: Requesting employee: Last First Middle initial Employee phone: Employee email: Work location: Office/location (e.g., program, district, branch office, city) Employee job title: Employee ID: Supervisor name: Phone:

Part 1: Intake 1. Why does the employee need an ADA accommodation?

2. What accommodation did the employee request? (Note: An employee may not know exactly what accommodation he or she needs or directly ask for it. In that case, HR may ask permission to seek suggestions from a health provider.)

3. Interactive process (required — select one): I have scheduled a time to discuss the request with the employee on this date: I met with the employee at least once to discuss the request and explore possible solutions. I have attached notes, documentation and/or the optional DHS 3002 ADA Interactive Process Checklist. 4. Submittal process a. Submit part I of this completed form to [email protected] no later than three working days from the employee’s request. b. Copy your HR representative. c. Complete and submit part II of this form when you have successfully THIS IS A CONFIDENTIAL MEDICAL RECORD. DO NOT PLACE IN THE EMPLOYEE’S PERSONNEL FILE. Page 1 of 2 DHS 3001 (03/2017) accommodated the employee.

Part 2: After accommodation is made 5. Attach DHS 3003 Accommodation Offer Letter and/or other documentation that details the agreed accommodation(s). 6. Please list any costs and equipment provided (below): Accommodation details (if applicable and known) Estimated total cost: $ Budget code: List equipment provided: 1. 2. 3. 4.

Approved by:

7. Date accommodation implemented: 8. Submit this form via email to [email protected]. Attach any notes, letters or other documentation. Copy your HR representative. The supervisor is responsible for regularly checking with the employee about the accommodation and working together to make necessary changes.

*Triggering duty: The legal term for when a supervisor should know that an employee needs an accommodation. See the DHS ADA Process for the requirements.

THIS IS A CONFIDENTIAL MEDICAL RECORD. DO NOT PLACE IN THE EMPLOYEE’S PERSONNEL FILE. Page 2 of 2 DHS 3001 (03/2017)