Chancellor S Diversity Initiative

ADA Coordinator Chancellor’s Diversity Initiative University of Missouri-Columbia ______S303 Memorial Union - Columbia MO 65211 – 573-882-9069 V/TTY - Fax: 573-884-4103 - [email protected] EMPLOYMENT ACCOMMODATION REQUEST

If you believe you may need an employment accommodation because of a disability, please complete this form and send it in a sealed envelope to Noel Ann English, S303 Memorial Union. If there is not enough space on the form for your answers, please add pages as necessary. In addition, please include a copy of your job description or information about the nature of your job responsibilities at MU, along with any additional information you think might be helpful in reviewing your request. The information you provide will assist MU in determining whether, and/or to what extent, reasonable accommodations may be required for you to perform the essential functions of your job. The ADA Coordinator will keep the form you complete confidential and separate from your personnel file. However, the information you provide may be shared with health care providers (see below).

TO: MU ADA Coordinator

FROM: ______(Name) ______(Social Security Number)

______(Address) ______(Phone Number)

___Faculty Member ___Staff Member ___Student/Employee (check one)

1. Identify and briefly describe the impairment(s) that limit your ability to perform the essential functions of your job and are the reason for your request for reasonable accommodations (see the definition of disability at the end of this form). What major life activities are substantially limited by your condition?

2. Identify and describe the essential function(s) of the position that you are unable to perform without reasonable accommodations (see definition of reasonable accommodation at the end of this form):

Page 2 3. Identify and describe the accommodation(s) you believe you need to enable you to perform the essential functions of your position. These accommodations might include but are not limited to special equipment, changes in the physical layout of your office or classrooms, etc.:

4. Identify and describe any special methods or procedures that would enable you to perform the essential functions of your position:

5. Identify and describe any equipment, aids, or services that you are willing to provide:

6. Provide the names and addresses of any physicians, therapists, psychologists, or other licensed health care providers who have information or documentation concerning your impairment as it affects your need for the employment accommodations you are requesting:

NAME: ______ADDRESS: ______PHONE: ______

7. If none, please explain why you have not obtained an evaluation or treatment.

8. Have any health care providers advised you not to perform any part of your current job? If yes, please provide details.

9. Please provide any other information you think would be helpful in reviewing your request:

Page 3 PLEASE READ THE FOLLOWING CAREFULLY, THEN SIGN AND DATE

I have a disability that I believe has, or may have, an adverse effect on my work performance. In order to minimize or eliminate the effect of the disability on my work performance, I am voluntarily requesting that MU review my situation for the purpose of considering a reasonable accommodation. I understand that submitting this form is an initial step only. I understand that MU will not assume, based on my submission of this form, that I am disabled or that a change or accommodation in the workplace is required.

I understand that MU must be able to confirm the existence and extent of the disability and how it may relate to the duties and responsibilities of the position involved. I understand that this information is necessary so that MU can respond to this request, and that this form and any attachments I have provided may be shared with the health care providers I have identified, as well as with other health care providers with whom MU may consult in evaluating this request.

I also understand that appropriate consideration of this request may require disclosure of information about my impairment to supervisors and others at MU who may have a need to know enough about the impairment to participate effectively in discussions about possible accommodations, and/or in implementing accommodations. I agree to provide any other information needed in order to respond to this request. I hereby authorize the above-listed health care providers and any others who have treated me to release to MU medical records concerning the impairment disclosed herein as it may affect my ability to perform the job in question, and to provide any opinions to MU concerning my ability to perform job-related functions with or without reasonable accommodation.

The foregoing statements are complete, accurate, and true to the best of my knowledge.

SIGNATURE OF EMPLOYEE: ______

DATE: ______

DEFINITIONS:

Disability: a physical or mental impairment that substantially limits one or more major life activities. Major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. A major life activity also includes the operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions.

Reasonable accommodation: any reasonable modification to the job or work environment to enable a qualified individual with a disability to perform the essential functions of the job.

Note: These definitions are provided only as a guide. Nothing in this form is intended to alter the legal definition of these terms or to impose obligations on the University of Missouri-Columbia not required by law.

Please also see: http://eeoc.gov/laws/types/disability.cfm

Revised March 2012