EARC Employment Accommodations Request Form

Building an Inclusive Workforce
Employment Accommodation
Request Form
SJSU Administration Bldg., Rm 114, One Washington Square, San José, CA 95192 · (408) 924-6003 v.; (408) 924-5990 TTY; (408) 924-4358 f.
The following employment accommodation request form is to be used by San José State University
employees who: (1) are currently registered with the Employment Accommodations Resource Center
(EARC); (2) are requesting continued and/or additional employment accommodations for an existing
condition(s) currently registered with the EARC; and (3) have previously received prescribed employment
accommodations by EARC for existing condition(s) currently registered with EARC. An employee
registered with the EARC has provided the EARC with medical/psychological disability verification that
qualifies him/her as an individual with a disability under FEHA and/or ADA, as amended.
The information you provide on this form will assist the EARC in determining reasonable and appropriate
employment accommodations, if applicable. Please answer all questions completely and to the best of your
ability. The information disclosed on this form is strictly confidential and will not be released without your
written permission. When you have completed this form, please submit it to the EARC along with any other
necessary documents. Please be advised that updated medical documentation may be required and is
determined at the discretion of the EARC on a case-by-case basis.
A. CONTACT INFORMATION
Name:
Empl ID#:
Home Address:
(Street)
(City)
Home Phone:
(State)
(Zip)
Work Phone:
(xxx) xxx-xxxx
Cell Phone:
(xxx) xxx-xxxx
Email:
(xxx) xxx-xxxx
Preferred Method of Contact (check all that apply):
Home
Work
Cell
Email
Special Instructions: (e.g., do not leave messages on work phone, etc.)
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B. EMPLOYMENT INFORMATION
(Please skip Section B entirely if your employment information has not changed since your last request.)
Employment Status:
Full-Time
Part-Time
Faculty:
Professor
Lecturer
FERP
Contractural
Staff:
Administrator
MPP
SSP
Admin
Skilled Craft
Technical
Maintenance
Casual Worker
Job Title:
Department:
Building/Room:
College/Division:
Direct Supervisor*:
(Name, Title & Phone No.)
(*In this intake, Direct Supervisor refers to your immediate supervisor or manager, i.e., Dean, Chair, MPP, or worklead.)
C. EMPLOYMENT ACCOMMODATION REQUEST INFORMATION
1. State and describe the condition(s) for which you are requesting an accommodation(s):
2. Due to your condition(s), which job duties are you having difficulty performing?
3. State your employment accommodation request(s). For employees requesting a student assistant or assistive
equipment as an accommodation, please also complete sections 3a or 3b, respectively (pages 3-4).
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3a. REQUEST FOR STUDENT ASSISTANT
The following information is to be completed by employees requesting a student assistant as an
employment accommodation.
Please list requested student assistant job duties. Note: Student assistants may not perform personal care needs,
personal business or work that is not specifically related to your current job duties.
Number of Weeks:
Number of Hours per Weeks:
Assistance is requested for the following semester(s):
Note: Pay rate will be determined by the EARC and based on the experience of the student and job skills
required.
3b. REQUEST FOR ASSISTIVE EQUIPMENT
The following information is to be completed by employees requesting assistive equipment as an
employment accommodation. The EARC relies upon employee to research for the product(s) that the
employee believes could support their accommodation needs. To better assist the EARC, employees are
encouraged to provide more than one product or vendor information (please feel free to attach product
information from vendor website, etc.) Note: The nature of the assistive equipment prescribed, if appropriate, will
be determined by the EARC.
State the nature of the assistive equipment you are requesting and describe how it will assist you on the job:
4. Describe how the requested accommodation(s), would assist you in the workplace.
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Provide equipment specifications (vendor name, product description, model #, and price):
Product:
Vendor:
Website:
Vendor Phone #:
Cost:
$
Cost:
$
(xxx) xxx-xxxx
Product:
Vendor:
Website:
Vendor Phone #:
(xxx) xxx-xxxx
NOTE: Departments are expected to provide maintenance and repair for equipment funded under the
EARC.
5. For faculty ONLY: If you are faculty requesting an employment accommodation(s) for the classroom, please
provide the current class schedule for which the employment accommodation(s) is being requested by
attaching a current course schedule to this form.
6. Please provide any additional information that might be useful in processing your accommodation request.
(Information provided must be specific and relevant to your current job duties and the condition for which
you are requesting accommodation(s).)
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A. EMPLOYMENT ACCOMMODATION REQUEST AGREEMENT, CERTIFICATION AND ACKNOWLEDGEMENT
Please read the following carefully, sign and date.
I have a condition that I believe has, or may have, an adverse effect on my work performance. In order to
minimize or eliminate the effect of the functional limitations of the condition on my work performance, I am
voluntarily requesting that EARC review my request(s) for the purpose of considering reasonable and
appropriate employment accommodation(s) through an interactive process involving myself, the EARC, and
my direct supervisor.
I understand that in order to be eligible for employment accommodations: (1) I must be a qualified SJSU
employee; (2) EARC must be able to confirm the existence and extent of the disability in accordance with the
criteria and requirements established under the California Fair Employment Housing Act (FEHA) and Title I of
the Americans with Disabilities Act (ADA), as amended; and (3) I must be able to demonstrate the functional
limitations of my condition has or may have an adverse effect on my work performance.
I understand that submitting this form is the initial step to requesting employment accommodation(s) through
the EARC and the information contained in this form is necessary to begin evaluation of my request. I
understand that EARC 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 in addition to this form, my request for employment accommodation(s) is not complete until
I provide comprehensive, legitimate medical/psychological disability verification documentation on the
condition(s) for which I am requesting accommodation(s). I understand that the EARC has the right to
determine the need for additional medical/psychological disability verification documentation and, if
determined necessary, has the discretion to request additional information/documentation from me or my
treating professional/physician. I understand I am responsible for providing legitimate medical/psychological
disability verification documentation regarding the condition(s) for which I am requesting employment
accommodation(s) to the EARC in order for the EARC to evaluate my request(s).
By signing this form, I certify my agreement with and acknowledgement to the foregoing statements and
certify the information I provided on this form is complete, accurate, and true to the best of my knowledge.
Employee Signature:
Date:
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B. CONSENT TO RELEASE INFORMATION
Please read the following carefully, sign and date.
I understand that appropriate evaluation of my request(s) may require disclosure of information regarding my
status as an employee with a qualified disability, if applicable, and/or the functional limitations of my
condition(s) to my direct supervisor(s), Faculty Affairs, Human Resources, and other individuals who need to
know enough about the condition to participate effectively in discussions regarding possible accommodations.
Should EARC prescribe employment accommodations, I understand that implementation and maintenance of
prescribed accommodation(s) may require disclosure of information regarding my status as an employee with
a qualified disability and/or the functional limitations of your condition to departmental administrative
support or individuals/departments (i.e., Academic Scheduling) in similar capacities who are involved in
departmental coordination (e.g., scheduling, budgeting, ordering, etc.) efforts. I understand EARC will not
authorize the individuals in departments referenced above access to my medical/psychological disability
verification documentation. Exceptions to maintaining confidentiality and the release of medical/
psychological disability verification documentation are as follow: (1) when I give my written permission for its
release; (2) in certain life or death emergencies; and (3) by court order.
I authorize EARC to contact the following individuals and/or departments for the purposes of evaluating,
implementing, or maintaining employment accommodation(s):
Name/Title/Dept/Phone
Name/Title/Dept/Phone
I hereby authorize the EARC to contact the treating the professional/physician stated below regarding the
medical condition(s) for which I am requesting an employment accommodation(s).
Please state the condition(s):
Treating Professional/Physician (i.e., M.D., Psychologist, Neurologist, Worker's Comp. Treating Physician etc.)
Name
Medical Facility
Address (City, State, Zip) and Phone Number
By signing this form, I hereby authorize EARC to consult with the aforementioned individuals/departments
for purposes of evaluation, implementing, and/or maintaining employment accommodations.
Employee Signature:
Date:
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