ADA Request for Reasonable Accommodation

County of El Paso ADA Request for Reasonable Accommodation

This form must be completed to make a request for accommodation due to a documented disability. To be eligible for a reasonable accommodation under the American with Disabilities Act (ADA), you must be qualified to perform the essential functions of your position with or without an accommodation and have a qualifying disability that substantially limits a major life function.

Employee Name: SS #: Date

Job Title: Work Schedule Phone:

Department Supervisor Supervisor phone

1) Please describe your medical condition and how it affects your ability to perform a major life activity? Please list the major life activities substantially limited by your medical condition(s) and how this life activity is substantially limited. Life activities include but are not limited to: caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, concentrating, eating, lifting, standing, working, sitting, reaching, thinking, interacting with others.

2) Describe any mitigating measures (medication, assistive technologies, wheelchairs, etc.) you are using due to a disability and the effect of those on your disability?

3) Describe in detail how your medical condition limits or impairs your ability to perform the essential functions of your position. Identify the essential functions of your position affected and how the medical condition impairs your ability to perform. Request for Accommodation 2

4) Describe in detail the type of accommodation that you are requesting: Please be specific.

5) Explain how the requested accommodation will enable you to perform the essential functions of your position.

6) Provide any information or suggestion on how the requested accommodation can be provided.

______Employee Signature Date

______Human Resources Representative Date Received Request for Accommodation 3 Please complete this form and provide it to Human Resources, located in the County Courthouse, 3rd Floor or mail to: Human Resources, County Courthouse, 500 E. San Antonio, Ste. 302, El Paso, Texas 79901.