"Request for Reasonable Accommodation Form" - City and County of San Francisco, California

Request for Reasonable Accommodation Form is a legal document that was released by the Department of Human Resources - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco.

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Ci ty and County of San Francisco
Department of Human Resources
Carol Isen
London Breed
Human Resources Director
Mayor
REQUEST FOR REASONABLE ACCOMMODATION FORM
Exams at the City and County of San Francisco may require you to do one or more of the following:
Listen to instructions about test content or administration
Sit at desks, in chairs, etc. for long periods of time
Watch a video relating to test content or administration
Speak in front of a panel of raters (e.g., oral examination)
Read and answer exam questions on a computer
Perform physical activities (e.g., physical ability tests)
Read exam material & fill in circles on a bubble sheet (e.g., multiple-choice examination)
Write answers in narrative form using a pen or pencil (e.g., essay examination)
This SECTION is to be COMPLETED by the APPLICANT
If you are disabled (have a physical/mental impairment that limits a major life activity) as defined by
the California Fair Employment and Housing Act and/or Americans with Disabilities Act and wish to
request a reasonable accommodation for a particular exam due to your disability, please complete the
following:
Applicant Name (PRINT):
Applicant Signature:
Date:
Recruitment ID #:
Title of Examination:
The following are types of test accommodations(s) that may be possible. Please check below the ones you
are requesting:
Visual /Learning
Hearing
□ Marker (someone to mark answers)
☐ Interpreter
□ Reader
☐ Separate Room
□ Separate Room
□ Extra Time
Mobility
□ Testing room as close as possible to entrance or restroom
□ Personal attendant (to be provided by candidate)
□ Accessible test area for persons who use a wheelchair
□ Special seating
□ Marker (someone to mark answers)
Please describe any other accommodations you would like to request:
After the front and back sections of this form are completed (the back section does not need to be completed if
your disability is obvious), you should return the form to the analyst who scheduled your exam (i.e., look for the
analyst name in the e m a i l you received about the exam).
Note: All information provided will be kept CONFIDENTIAL. If you later need an accommodation to perform essential job functions
upon hire, you must submit a separate request to the employing department.
Ci ty and County of San Francisco
Department of Human Resources
Carol Isen
London Breed
Human Resources Director
Mayor
REQUEST FOR REASONABLE ACCOMMODATION FORM
Exams at the City and County of San Francisco may require you to do one or more of the following:
Listen to instructions about test content or administration
Sit at desks, in chairs, etc. for long periods of time
Watch a video relating to test content or administration
Speak in front of a panel of raters (e.g., oral examination)
Read and answer exam questions on a computer
Perform physical activities (e.g., physical ability tests)
Read exam material & fill in circles on a bubble sheet (e.g., multiple-choice examination)
Write answers in narrative form using a pen or pencil (e.g., essay examination)
This SECTION is to be COMPLETED by the APPLICANT
If you are disabled (have a physical/mental impairment that limits a major life activity) as defined by
the California Fair Employment and Housing Act and/or Americans with Disabilities Act and wish to
request a reasonable accommodation for a particular exam due to your disability, please complete the
following:
Applicant Name (PRINT):
Applicant Signature:
Date:
Recruitment ID #:
Title of Examination:
The following are types of test accommodations(s) that may be possible. Please check below the ones you
are requesting:
Visual /Learning
Hearing
□ Marker (someone to mark answers)
☐ Interpreter
□ Reader
☐ Separate Room
□ Separate Room
□ Extra Time
Mobility
□ Testing room as close as possible to entrance or restroom
□ Personal attendant (to be provided by candidate)
□ Accessible test area for persons who use a wheelchair
□ Special seating
□ Marker (someone to mark answers)
Please describe any other accommodations you would like to request:
After the front and back sections of this form are completed (the back section does not need to be completed if
your disability is obvious), you should return the form to the analyst who scheduled your exam (i.e., look for the
analyst name in the e m a i l you received about the exam).
Note: All information provided will be kept CONFIDENTIAL. If you later need an accommodation to perform essential job functions
upon hire, you must submit a separate request to the employing department.
Ci ty and County of San Francisco
Department of Human Resources
Carol Isen
London Breed
Mayor
Human Resources Director
REQUEST FOR REASONABLE ACCOMMODATION FORM
[Note: If your disability is obvious, it is NOT necessary for you to have this side of this form completed.]
This SECTION is to be COMPLETED by a MEDICAL DOCTOR, SCHOOL PSYCHOLOGIST,
LEARNING CONSULTANT, etc. as appropriate.
Exams with the City and County of San Francisco are administered on the basis of fairness, merit and
equal opportunity. They are often highly competitive and candidates are ranked on score reports based on
their test score. The applicant who has signed the other side of this form is taking an exam and is requesting a
reasonable accommodation during the exam. Whenever possible, reasonable testing accommodations that
can be supported are provided to applicants with disabilities.
Please review the applicant’s medical or educational history (as appropriate). If you support the applicant’s
request for the reasonable accommodation(s), please complete the information below and return the form to
the applicant.
Print Candidate Name:
I certify that the above-named individual is disabled as defined by the California Fair Employment and Housing
Act and/or Americans with Disabilities Act. Consequently, I recommend that the following Special
Accommodation(s) be provided to this individual during the exam:
Print (as appropriate) the name of the medical
Signature (as appropriate) of the name of the
doctor, school psychologist, or learning
medical doctor, school psychologist, or
consultant.
learning consultant.
(Street Address)
Certificate or License No. and State - (if
applicable)
(City) (State) (Zip)
(Phone Number)
(Date Signed)
Note: All information provided will be kept CONFIDENTIAL. If you later need an accommodation to perform essential job functions
upon hire, you must submit a separate request to the employing department.
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