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

Employee Request for Reasonable Accommodation 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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  • Released on February 3, 2020;
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City and County of San Francisco
Department of Human Resources
Connecting People with Purpose
Human Resources Director
www.sfdhr.org
Employee Request for Reasonable Accommodation
Name: _______________________________DSW#: __________________Class/Title: _______________
Address: _____________________________City:______________________ State: _____ Zip: ________
Contact No.: _____________________________ Personal Email: ________________________________
Dept.: _______________________________________________________________________________
It is the policy of the City and County of San Francisco to provide reasonable accommodations to
qualified individuals with disabilities in accordance with the federal Americans with Disabilities Act
(ADA) and the California Fair Employment and Housing Act (FEHA). You may be required to provide
documentation in support of your request for reasonable accommodation. Please note that this
information will be maintained in a separate confidential file from your personnel file and access will
be limited only to those with a need-to-know.
I. Reasonable Accommodation Request:
Purchase of assistive device(s)
Removal of communications barrier
Job Restructuring
Purchase of assistive services
Removal of architectural barrier
Modified Reassignment
Other (specify): ____________________________________________________________________
Please describe the accommodation: (use extra sheets if need) ________________________________
____________________________________________________________________________________
II. Essential Duties of Your Position:
Please identify the essential duties (do not include marginal duties) of your position for which you are
requesting an accommodation:
1.
______________________________________________________________________________
2.
______________________________________________________________________________
3.
______________________________________________________________________________
4.
______________________________________________________________________________
III. Health Care Provider:
Please provide us with the name of your health care provider(s) who can assist with this request: (use
extra sheets if needed)
Name:
__________________________________________________________________
Address: __________________________________________________________________
Phone:
__________________________________________________________________
Specialty: __________________________________________________________________
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
City and County of San Francisco
Department of Human Resources
Connecting People with Purpose
Human Resources Director
www.sfdhr.org
Employee Request for Reasonable Accommodation
Name: _______________________________DSW#: __________________Class/Title: _______________
Address: _____________________________City:______________________ State: _____ Zip: ________
Contact No.: _____________________________ Personal Email: ________________________________
Dept.: _______________________________________________________________________________
It is the policy of the City and County of San Francisco to provide reasonable accommodations to
qualified individuals with disabilities in accordance with the federal Americans with Disabilities Act
(ADA) and the California Fair Employment and Housing Act (FEHA). You may be required to provide
documentation in support of your request for reasonable accommodation. Please note that this
information will be maintained in a separate confidential file from your personnel file and access will
be limited only to those with a need-to-know.
I. Reasonable Accommodation Request:
Purchase of assistive device(s)
Removal of communications barrier
Job Restructuring
Purchase of assistive services
Removal of architectural barrier
Modified Reassignment
Other (specify): ____________________________________________________________________
Please describe the accommodation: (use extra sheets if need) ________________________________
____________________________________________________________________________________
II. Essential Duties of Your Position:
Please identify the essential duties (do not include marginal duties) of your position for which you are
requesting an accommodation:
1.
______________________________________________________________________________
2.
______________________________________________________________________________
3.
______________________________________________________________________________
4.
______________________________________________________________________________
III. Health Care Provider:
Please provide us with the name of your health care provider(s) who can assist with this request: (use
extra sheets if needed)
Name:
__________________________________________________________________
Address: __________________________________________________________________
Phone:
__________________________________________________________________
Specialty: __________________________________________________________________
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
Employee Request for Reasonable Accommodations
Health Care Provider (Additional):
Name:
__________________________________________________________________
Address: __________________________________________________________________
Phone:
__________________________________________________________________
Specialty: __________________________________________________________________
IV. Major Life Activities:
Please check the major life activity/activities you believe to be limited by your medical condition(s):
Walking
Breathing
Seeing
Caring for Oneself
Working
Talking
Hearing
Learning
Performing Manual Tasks
Other: __________________
Please described how the above activity/activities is/are limited: ______________________________
___________________________________________________________________________________
___________________________________________________________________________________
a. Is your medical condition temporary?
Yes
No
If yes, please stated the expected duration: ______________________________________________
b. Are you currently working?
Yes
No
If no, please specify the type of leave currently approved and the duration (dates):
__________________________________________________________________________________
c. Have you previously applied for a reasonable accommodation within the City?
Yes
No
If yes, please explain the status/circumstances: ___________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I hereby certify that I believe I am a qualified individual with a disability as defined by the law. I have
received and reviewed the information brochure and require an accommodation to perform the
essential functions of my position. I understand that a detailed review of my disability status may be
required, and I agree to cooperate fully in this process. I further understand that if my request is
granted, I am obligated to report any changes in my disability status which may require a re-
evaluation of this request. Granting of this request does not signify approval of any future reasonable
accommodation request for any other position within this department or any other department
within the City and County of San Francisco.
_______________________________________
_________________________________
Employee Signature
Date
Page 2 of 2
(Rev. 2/3/2020)
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