Employing People With Disabilities: Procedure 600.000
Selecting a
Reasonable Accommodation
Applicant’s or employee’s name: _____________________________________________________
Job under consideration (attach job analysis and job description): ___________________________
Describe the applicant’s or employee’s functional limitations as they affect performance of the job:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1. Consultation
with Application or Employee:
Who consulted with the applicant or employee? ______________________________________
Date of consultation: _________________________
Applicant’s or employee’s description of functional limitations that affect job performance:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Accommodation(s) suggested by applicant or employee: _______________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. Other
Sources of Information About Applicant’s or Employee’s Functional Limitations:
Describe other sources of information about the applicant’s or employee’s functional limitations as they affect job performance, including information received from the District selected physician, the applicant’s or employee’s physician, organizations with general knowledge about the applicant’s or employee’s condition, written material, etc.
Source of information: __________________________________________________________
Information received: ___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Source of information: __________________________________________________________
Information received: ___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Sources
of Information About Possible Accommodation(s):
Describe other sources of information about possible accommodation(s), including information received from the District selected physician, the applicant’s or employee’s physician, vocational experts, organizations with general knowledge about the applicant’s or employee’s condition, written material, etc.
Source of Information: __________________________________________________________
Accommodation(s) suggested: ____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Source of Information: __________________________________________________________
Accommodation(s) suggested: ____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Accommodation(s)
Considered:
Describe the accommodation(s) considered and how each will or will not overcome the applicant’s or employee’s job related functional limitations. For those accommodations that will be effective, determine whether providing the accommodation would be an undue hardship and attach the undue hardship analysis to this form.
Q Purchase of assistive device: ___________________________________________________
______________________________________________________________________________
Q Purchase of assistive services: __________________________________________________
______________________________________________________________________________
Q Job restructuring: ____________________________________________________________
______________________________________________________________________________
Disabilities: Selecting a Reasonable
Accommodation: