Cty Summer Programs Staff Request for Reasonable Workplace Accommodation Form

CTY SUMMER PROGRAMS STAFF REQUEST FOR REASONABLE WORKPLACE ACCOMMODATION FORM

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This form will not be placed with your application or in your personnel file. Contents of this request will be kept in confidence except as needed to address the request for an accommodation. The CTY summer staff member has the responsibility to ensure that the medical provider follows through on requests for medical information.

If you require an alternative version of this form, please contact CTY Disability Services at or calling 410-735-6206.

Send this completed form to Melissa Kistler or Abigail Hurson, JHU’s Disability Officer:

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Melissa Kistler, CTY Disability Services Administrator

McAuley Hall, Suite 400, 5801 Smith Ave. Baltimore, MD 21209

Phone 410.735.6206/ Fax 410.800.4060

http://cty.jhu.edu/disability/workplace/index.html

Emily Lucio, JHU Director of ADA Compliance

3400 N. Charles Street, Wyman Park Building, Suite 515 Baltimore, MD 21218-2696

Phone 410.516.8949 / Fax 410.516.5300 / TTY 410.516.6225

http://web.jhu.edu/administration/jhuoie/disability.html

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PART A: To be completed by the CTY summer staff member.

Date of Request:

Name:

Position Title:

Site Program Manager/Assistant Program Manager:

CTY Site Location:

Home Address:

Home Phone:

Cell Phone:

Email:

How would you prefer to be contacted? Please select one.

Home Phone Cell Phone Email

PART B: To be completed by the employee and reviewed by CTY’s Disability Services Administrator or JHU’s Director for ADA Compliance and Disability Services during a personal interview with the employee.

1.  What is the nature of your disability, including your diagnosis?

2.  Is this a permanent or temporary disability? If temporary, what is the duration of your condition?

3.  What work-related limitations caused by your disability are you currently experiencing?

4.  What are the essential functions of your job? If possible, please attach your current job description.

5.  Describe the accommodations you are requesting, including any adaptive equipment. Be specific as possible.

6.  Are you in need of an individual emergency evacuation plan? If so, please indicate what accommodation you would need for this plan?

PART C: To be signed by the staff member after the personal interview with the CTY’s Disability Services Administrator or JHU’s Director of ADA Compliance. At the conclusion of the evaluation, disability services will work with your supervisor and other appropriate University entities to address your request.

VERIFICATION AND ACCURACY

·  I verify that the above information is complete and accurate to the best of my knowledge.

·  I also understand that my request for an accommodation may not be granted if it is not reasonable or if it creates an undue hardship on my employer.

·  By signing below, I understand that I am granting CTY Disability Services and the JHU Office of Institutional Equity permission to contact the appropriate individuals and/or offices to determine my request for reasonable accommodation.

Signature: ______Date: ______

Print or Type Name:

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