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The form explains reasonable accommodations as changes or adaptations needed for qualified employees to perform essential job functions without placing undue hardship on the university. Applicants attach an Employment Accommodation Medical Certification completed by a qualified medical professional and provide contact, employment, and request details including limitations, job duties affected, and the accommodations requested. 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All requests are treated as confidential information and will be considered on a case‐by‐case basis. Reasonable accommodations are defined as those changes or adaptations necessary for employees with qualifying disabilities to perform essential job functions, which are reasonable for the university to provide and do not place an undue hardship on the university. Cal Poly provides reasonable accommodations to employment in accordance with provisions contained in the Americans with Disabilities Act (ADA) as amended, Section 504 of the Rehabilitation Act, and California’s Fair Employment and Housing Act (FEHA) .  \nBefore submitting this form, you will be asked to attach an Employment Accommodation Medical Certification, completed by a qualified medical professional, as documentation of your disability. In completing this Medical Certification, your physician/treatment provider should review your position description in order to determine with you which essential functions need accommodating. (For Faculty, see CFA-CSU Collective Bargaining Agreement Article 20 (Workload) . ) For more information go to: [https://afd.calpoly.edu/hr/employee-resources/requesting-accommodation](https://afd.calpoly.edu/hr/employee-resources/requesting-accommodation. HR)[. HR](https://afd.calpoly.edu/hr/employee-resources/requesting-accommodation. HR) or Academic Personnel will then evaluate your functional abilities and limitations, analyze your job requirements and assist the department in exploring possible accommodations. Often, you will be required to engage with HR and your department in this process in order to explore and decide on a reasonable accommodation.  \nDate of Request:    \nA. Contact Information  \nName:   Email:    \nCell Phone:   Home Phone:    \nPreferred Method of Contact (check all that apply): Cell Phone Home Phone Email Special Instructions: (e.g., do not leave messages on work phone, etc. ):  \nB. Employment Information  \nCurrent Work Schedule:    \nEmployment Status (select choice in each of the three categories):  \nJob Title:     \nDepartment:   Work Location Building/Room:    College/Division:     \nDirect Supervisor:   Supervisor Title:    \nIn this intake, Direct Supervisor refers to your immediate supervisor or manager, i.e., Appropriate Administrator, Dean, or Department Head/Chair  \nC. Employment Accommodation Request Information  \nState and describe the reasons why you are requesting accommodation(s) (i.e., limitations, impairments, restrictions, injuries) You do not need to disclose your diagnosis.  \nAnticipated Disability Duration:  \nHave you requested accommodations from your direct supervisor?  \nIf Yes, with what result / response:     \nHave you applied for or are you currently using any disability leave programs through Human Resources such as NonIndustrial Disability Insurance (NDI), Family and Medical Leave (FML), etc.?  \nIf yes, please state which program:   Do you have an open or pending Worker's Compensation claim for this/these condition(s)?  \nIf your Worker’s Compensation claim is completed, please state any modifications/accommodations you receive through Worker's Compensation:  \nUnder the ADA, a disability is a “Physical or Mental Impairment that substantially limits one or more of the major life activity of such individual.” Major life activities are such functions as performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. (This list of major life activities is meant to be illustrative rather than exhaustive.) Under California’s FEHA, an individual with a disability has a physical or mental condition that limits a major life activity or has a","cbCainPT69KjmVqp","https://ap.wps.com/l/cbCainPT69KjmVqp","pdf",200319,"English","# Date of Request\n# A. Contact Information\n## Preferred Method of Contact\n## Special Instructions\n# B. Employment Information\n## Employment Status\n## Work Location\n## Direct Supervisor\n# C. Employment Accommodation Request Information\n## Reasons for Request\n## Disability Duration\n## Supervisor and Leave Program History\n## Worker’s Compensation Claim\n## ADA/FEHA Definitions and Job Impact Questions\n## Limitations and Job Duties Affected\n## Requested Accommodations\n## Past or Current Accommodations\n## Employee Signature and Date","[{\"question\":\"What is the purpose of this form?\",\"answer\":\"The form is used to make a formal request for employment accommodation due to disability. Requests are treated as confidential and considered case-by-case.\"},{\"question\":\"What additional document must be submitted before the request is complete?\",\"answer\":\"The request is not complete until an Employment Accommodation Medical Certification is also submitted. HR may contact the treatment provider for additional information if needed.\"},{\"question\":\"What information should be included in the accommodation request section?\",\"answer\":\"Applicants should describe the reasons for the request, anticipated disability duration, how limitations affect job performance and impacted duties, and what accommodations are believed to enable the job functions. The form also asks about prior or current workplace accommodations.\"}]","Employment Disability Accommodation Request Form - Request for employment accommodation | PDF",1789538085]