1 Sample Request for RA Equipment (00286132)

REASONABLE ACCOMMODATION

Sample Forms and Letters for Individuals with Disabilities

180 Montgomery Street, Suite 600

san francisco, california 94104

tel: 415 864 8848 www.las-elc.org

SAMPLE REQUEST FOR ACCOMMODATION

Ergonomic Equipment, Other Equipment

MEMORANDUM

TO: (1) ____________________________

FROM: (2) ____________________________

RE: Request for Reasonable Accommodation

DATE: (3) ________________________

This is a request for reasonable accommodation under the Americans with Disabilities Act (ADA) and the California Fair Employment and Housing Act (FEHA). If you are not the appropriate person to receive this request, please notify me immediately, and forward this letter on to the person who handles requests for reasonable accommodation.

I am a person with a “disability” under the ADA and the FEHA. [My condition is (4) ____________________.] Due to my disability, I need (5) ____________________________________.

According to the ADA and the federal Equal Employment Opportunity Commission (EEOC), providing specialized equipment is a form of reasonable accommodation. See 42 U.S.C. § 12111(9)(B) and EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act (Oct. 17, 2002), both available at www.eeoc.gov.

Please let me know if you require reasonable medical documentation of my condition, or if you wish to propose alternative accommodations to those I have requested. I am available and eager to engage in the interactive process with you.

Thank you.

(1) Name of Human Resources director, supervisor, program director, or another manager

(2) Your name

(3) Today’s date

(4) Optional: State the name or a description of your condition using language you feel comfortable with.

(5) Describe the equipment you need and how it relates to your disability. For example, “a captioned telephone because I am hard of hearing.” or “an ergonomic keyboard to prevent exacerbation of my carpal tunnel.”

Disability-related equipment in the workplace might include: video phone; captioned phone; visual doorbell; text-to-screen software (e.g. JAWS); voice recognition software (e.g Dragon Naturally Speaking); text pager; ergonomic chair; ergonomic keyboard; tracking ball; telephone head set; air filter; space heater; automatic door opener.

SAMPLE REQUEST FOR ACCOMMODATION

Changes to Physical Environment,

Removing Physical Access Barriers

MEMORANDUM

TO: (1) ____________________________

FROM: (2) ____________________________

RE: Request for Reasonable Accommodation

DATE: (3) ________________________

I am a person with a “disability” under state and federal laws. [My condition is (4) _________________.] As a result of my disability, I need (5) ______________________________________________.

According to the ADA and the federal Equal Employment Opportunity Commission (EEOC), removing physical access barriers is a form of reasonable accommodation. See 42 U.S.C. § 12111(9)(A) and the section entitled “General Principles” and Question 46 in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, both available at www.eeoc.gov.

Please let me know if you require reasonable medical documentation of my condition, or if you wish to propose alternative accommodations to those I have requested. I am ready and willing to engage in the interactive process with you so that I may continue in my employment.

Thank you.

(1) Name of Human Resources director, supervisor, program director, or another manager

(2) Your name

(3) Today’s date

(4) Optional: State the name or a description of your condition using language you feel comfortable with.

(5) Describe the change you are seeking and how it relates to your disability. Examples:

“It is difficult for me to navigate my wheelchair in my assigned cubicle. I am requesting to be moved into a larger cubicle with an accessible desk.”

“The bathroom is not accessible for me and my scooter. I am requesting that the company combine two stalls into one larger stall.”

“My disability affects my ability to concentrate. I am requesting a quieter work station with fewer distractions. I could move to one of the cubicles in the corner, or a partition could be added to my current cubicle.”

“I use a lift-equipped van, and need an accessible parking spot near the entrance.”

SAMPLE REQUEST FOR ACCOMMODATION

Modified or Part-Time Schedule

MEMORANDUM

TO: (1) ____________________________

FROM: (2) ____________________________

RE: Request for Reasonable Accommodation

DATE: (3) ________________________

I am a person with a “disability” under state and federal laws. [My condition is (4) _______________________.] Due to my disability, (5) __________________________________________________.

According to the ADA and the federal Equal Employment Opportunity Commission (EEOC), a modified or part-time schedule can be a form of reasonable accommodation. See 42 U.S.C. § 12111(9)(B) and the sections entitled “Leave” and “Modified or Part-Time Schedule” in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, both available at www.eeoc.gov.

Thank you.

(1) Name of Human Resources director, supervisor, program director, or another manager

(2) Your name

(3) Today’s date

(4) Optional: State the name or a description of your condition using language you feel comfortable with.

(5) Explain the modified schedule you are seeking and how it relates to your disability. Examples:

“My treatments for cancer are causing fatigue. I would like to work a part-time schedule of 20 hours per week for the next six months.”

“My medication is causing me to be groggy and nauseous in the morning. I would like to change my start time from 8:30 a.m. to 9:30 a.m., and then work until 6:00 p.m.”

“Because of my seizure disorder, my doctor has advised me to avoid night and swing shifts. I would like to work a regular daytime schedule.”

“I have a therapy appointment every Wednesday at 1:00 p.m. I would like to take a long lunch on Wednesdays and make up the time later.”

SAMPLE REQUEST FOR ACCOMMODATION

Modified Workplace Policy

MEMORANDUM

TO: (1) ____________________________

FROM: (2) ____________________________

RE: Request for Reasonable Accommodation

DATE: (3) ________________________

I am a person with a “disability” under state and federal laws. [My condition is (4) _________________.] Due to my disability, I am requesting the following modification of workplace policy: (5) ______________________________________________.

According to the ADA and the federal Equal Employment Opportunity Commission (EEOC), modified policies are a form of reasonable accommodation. See 42 U.S.C. § 12111(9)(B) and the section entitled “Modified Workplace Policies” in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, both available at www.eeoc.gov.

Thank you.

(1) Name of Human Resources director, supervisor, program director, or another manager

(2) Your name

(3) Today’s date

(4) Optional: State the name or a description of your condition using language you feel comfortable with.

(5) Describe the modification to the workplace policy or rule you are seeking and how it relates to your disability. Examples:

“Due to my cancer treatments, I need to constantly drink water. I would like to carry water on the floor.”

“I would like to use a stool while working the checkout station because of my knee and ankle injury.”

“Because of my disability, I have difficulty concentrating and can get startled by noises around me. I would like to listen to music on headphones at work.”

“Because of my diabetes, I sometimes need to eat immediately. I would like to keep food at my desk.”

“Because of my disability, I need unscheduled bathroom breaks – I cannot wait for my scheduled break.”

“I need an extension of leave beyond what is provided in our employee handbook.”

“I need a transfer even though I haven’t been in my current assignment the minimum year.”

SAMPLE REQUEST FOR ACCOMMODATION

Job Restructuring (Reassigning or Reorganizing Tasks)

MEMORANDUM

TO: (1) ____________________________

FROM: (2) ____________________________

RE: Request for Reasonable Accommodation

DATE: (3) ________________________

I am a person with a “disability” under state and federal laws. [My condition is (4) ___________________________.] Due to my disability, (5) _______________________________________.

According to the ADA and the federal Equal Employment Opportunity Commission (EEOC), job restructuring is a form of reasonable accommodation. See 42 U.S.C. § 12111(9)(B) and the sections entitled “Reasonable Accommodation” and “Job Restructuring” in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, both available at www.eeoc.gov.

Thank you.

(1) Name of Human Resources director, supervisor, program director, or another manager

(2) Your name

(3) Today’s date

(4) Optional: State the name or a description of your condition using language you feel comfortable with.

(5) Specifically explain the change that you need and why. Examples:

“Because I am hard of hearing, I have difficulty understanding strangers on the phone. I would like to be excused from answering the phone, which I do not understand to be a core function of my job. I am willing to take on a different task as needed.”

“I am often fatigued in the afternoon. I would like to switch the order in which I perform my duties, so that I perform my physical tasks (unpacking boxes) in the morning and my sedentary tasks (data entry) in the afternoon.”

“I am part of a three-person painting crew that is sent out to prepare and paint interiors. Because of my seizure disorder, I would like to be excused from the ladder work. The other people on my crew are available to work on the ladder, and I can do any other prep and finish work.”

Note: You must still be considered “qualified” to perform the basic duties of your job or another vacant position.

SAMPLE REQUEST FOR ACCOMMODATION

Adjusting Supervisory Methods

MEMORANDUM

TO: (1) ____________________________

FROM: (2) ____________________________

RE: Request for Reasonable Accommodation

DATE: (3) ________________________

I am a person with a “disability” under state and federal laws. [My condition is (4) _________________.] As a result of my disability, (5) _________________________________________.

According to the federal Equal Employment Opportunity Commission (EEOC), adjusting supervisory methods is a form of reasonable accommodation. See Question 33 in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, available at www.eeoc.gov.

Thank you.

(1) Name of Human Resources director, supervisor, program director, or another manager

(2) Your name

(3) Today’s date

(4) Optional: State the name or a description of your condition using language you feel comfortable with.

(5) Explain why you need an adjustment to supervisory methods because of your disability. Examples:

“I have difficulty with organization and time management due to my ADHD. I would like to meet with my supervisor once a month to review assigned tasks and deadlines.”

“Because of my intellectual disability, I need to have my job broken up into smaller tasks. I would like my supervisor to work with me and my job coach to develop a checklist for each of my work stations.”

“I have trouble following oral directions due to a learning disability. I am requesting that my supervisor follow up meetings with an email summarizing instructions.”

“I am experiencing anxiety during interactions with my supervisor because she speaks quickly and sometimes raises her voice in front of my coworkers. I am requesting that my supervisor hold counseling sessions in her office, and that she slow down so that I can take notes.”

SAMPLE REQUEST FOR ACCOMMODATION

Leave of Absence

MEMORANDUM

TO: (1) ____________________________

FROM: (2) ____________________________

RE: Request for Reasonable Accommodation

DATE: (3) ________________________

I am a person with a “disability” under state and federal laws. [My condition is (4) _________________.] I am requesting a leave of absence. (5) __________________________________________. My scheduled return to work date is (6) _______.

According to the federal Equal Employment Opportunity Commission (EEOC), a leave of absence is a form of reasonable accommodation. See the section entitled “Leave” and corresponding examples in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, available at www.eeoc.gov.