LAC 22:I.203. Request for Accommodation

REQUEST FOR ACCOMMODATION FORM SECTION 1: REQUESTOR INFORMATION Requestor’s Name:__________________________________________ Requestor is (check only one): Employee Job Applicant Visitor / Public Requestor’s Email Address: _____________________________________________________________ Requestor’s Phone #: ________________________________ If Requestor is an employee, also provide: Job Title: _________________________________________ Division/Unit:________________________ Supervisor’s Name: _________________________________ SECTION 2: REQUESTED ACCOMMODATION (Attach a separate sheet if additional space is needed) A. Please describe the nature of your disability and the functional limitations resulting therefrom. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ B. Check the type of accommodation requested. Use the blank space provided to the right to further explain reason for the requested accommodation. Accommodation Type: | Reason for Accommodation Request: 1. | Application/Testing Process Explain the specific application/testing requirement for which accommodation is requested: () 2. | Participating in a Job Interview Identify the Date/Time/Location of the job interview for which an accommodation is requested: () 3. | Performance of Essential Functions of Your Job Explain the job duties for which accommodation is requested: () 4. | Benefits/Privileges of Employment Explain the benefits or privileges of employment for which accommodation is requested: () 5. | Pregnancy, Childbirth or Related Condition Explain how pregnancy, childbirth or a related condition affects your ability to perform your job: () 6. | Effective Communication Identify the Date/Time/Location for which an auxiliary aid is requested: () 7. | Access to Programs, Services or Facilities Identify the specific program, service or facility for which access is needed: () C. Describe the accommodation(s) requested. (Identify specific auxiliary aid requested, if applicable) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Requestor’s Signature: _________________________________________ Date: ___________________ SECTION 3: TO BE COMPLETED BY AGENCY ADA COORDINATOR a. Process Tracking: 1. Date the Request for Accommodation was prepared/signed by Requestor: _____________ 2. Date the Request for Accommodation was received by ADA Coordinator: _____________ 3. Date of initial contact with Requestor (initiate interactive process): _____________ 4. Date(s) of follow-up contact with Requestor: _____________ _____________ ____________ 5. Date the Request for Accommodation was discussed with Appointing Authority: ___________ 6. If applicable, date the alternative accommodation(s) was discussed with Requestor: ___________ 7. Date Requestor was notified of final accommodation determination: _____________ 8. Date Requestor was notified of internal grievance procedure: _____________ b. Is there an equally effective accommodation(s), other than the one requested, that would satisfy the request? (Consult with www.askjan.org or Louisiana Rehabilitation Services, if necessary) Yes No If Yes, please identify: _________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ c. Was an accommodation granted? Yes (Proceed to section d. below) No (Proceed to section e. below) d. Accommodation Granted: Was the accommodation granted the same as the one requested? Yes No If an alternative, equally effective accommodation was granted, explain the reason this option was selected rather than the one requested. (Reason for alternative accommodation should be fully documented.) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ e. Denial of Accommodation: Check reason for denial and provide further explanation below. (Denials should be fully documented.) ADA Title I (for employees / applicants) Requestor is not a “qualified individual” (See Definition in agency policy) Accommodation would pose an undue hardship to the agency Accommodation would not eliminate direct threat of substantial harm to safety of individual or others | ADA Title II (for visitor / public) Requestor is not a “qualified individual” (See Definition in agency policy) Accommodation would fundamentally alter the nature of the agency’s service, program or activity Accommodation would not eliminate direct threat of substantial harm to safety of individual or others _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ADA Coordinator’s Signature: ________________________________ Date: _____________________