"Ada Reasonable Accommodation Request Form" - Delaware

Ada Reasonable Accommodation Request Form is a legal document that was released by the Delaware Department of Human Resources - a government authority operating within Delaware.

Form Details:

  • Released on September 1, 2020;
  • The latest edition currently provided by the Delaware Department of Human Resources;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Department of Human Resources.

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Download "Ada Reasonable Accommodation Request Form" - Delaware

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State of Delaware
Department of Human Resources
Reasonable Accommodation Request Form
Americans with Disabilities Act (ADA)
Authority: Americans with Disabilities Act
Policy #: To be assigned.
Amendments Act of 2008 (ADA)
Effective Date: September 1, 2020
Supersedes:
The purpose of the questionnaire is to determine whether an employee qualifies for an accommodation consistent
with the Americans with Disabilities Act (ADA) and, if so, to identify reasonable accommodations. Please
respond completely and attach appropriate backup documentation (e.g., medical certification). This form
should be completed by ADA Coordinator/Human Resources, in consultation with the supervisor
(when appropriate) and the employee for whom the accommodation is sought.
PART 1:
Employee Name: _______________________________________ Position: ________________________
Agency/Division: _______________________________________ Unit/Facility: ____________________
Email/Phone: __________________________________________
PART 2:
1. What limitation is interfering with the employee’s ability to perform the job or access a benefit or privilege of
employment? ______________________________________________________________________________
_________________________________________________________________________________________
2. What is the specific job function or work activity being impacted or limited by the disabling condition AND
to what extent (e.g., keyboard placement)? _______________________________________________________
_________________________________________________________________________________________
3. What is the specific accommodation(s) being requested? __________________________________________
______________________________________________________________________________
a. How does the accommodation enable the employee to perform the essential functions of the job?
____________________________________________________________________________________
____________________________________________________________________________________
b. If applicable, provide additional accommodations that may be appropriate.
____________________________________________________________________________________
____________________________________________________________________________________
4. Please include additional, relevant information. _________________________________________________
__________________________________________________________________________________________
FINAL
1 |
P a g e
State of Delaware
Department of Human Resources
Reasonable Accommodation Request Form
Americans with Disabilities Act (ADA)
Authority: Americans with Disabilities Act
Policy #: To be assigned.
Amendments Act of 2008 (ADA)
Effective Date: September 1, 2020
Supersedes:
The purpose of the questionnaire is to determine whether an employee qualifies for an accommodation consistent
with the Americans with Disabilities Act (ADA) and, if so, to identify reasonable accommodations. Please
respond completely and attach appropriate backup documentation (e.g., medical certification). This form
should be completed by ADA Coordinator/Human Resources, in consultation with the supervisor
(when appropriate) and the employee for whom the accommodation is sought.
PART 1:
Employee Name: _______________________________________ Position: ________________________
Agency/Division: _______________________________________ Unit/Facility: ____________________
Email/Phone: __________________________________________
PART 2:
1. What limitation is interfering with the employee’s ability to perform the job or access a benefit or privilege of
employment? ______________________________________________________________________________
_________________________________________________________________________________________
2. What is the specific job function or work activity being impacted or limited by the disabling condition AND
to what extent (e.g., keyboard placement)? _______________________________________________________
_________________________________________________________________________________________
3. What is the specific accommodation(s) being requested? __________________________________________
______________________________________________________________________________
a. How does the accommodation enable the employee to perform the essential functions of the job?
____________________________________________________________________________________
____________________________________________________________________________________
b. If applicable, provide additional accommodations that may be appropriate.
____________________________________________________________________________________
____________________________________________________________________________________
4. Please include additional, relevant information. _________________________________________________
__________________________________________________________________________________________
FINAL
1 |
P a g e
Reasonable Accommodation Request Form
Policy #: To be assigned.
Americans with Disabilities Act (ADA)
Rev. Date:
PART 3:
Name of person completing form: ______________________________________________________________
Title: ______________________________________________
Employee Signature: _____________________________________________ Date: ___________________
☐ By using this form, the parties acknowledge their agreement to conduct transactions by electronic means. A party’s
electronic signature for purpose of the Uniform Electronic Transactions Act, 6 Del. C., Ch. 12A, may be provided by
checking a box as indicated, electronic initials or name, or email confirmation.
FINAL
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P a g e
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