MAA AMERICANS WITH DISABILITIES ACT (ADA) REASONABLE ACCOMMODATION REQUEST
The purpose of this form is to assist MAA in determining whether, or to what extent, a reasonable accommodation is required for an employee with a disability to perform one or more essential functions of their job. This form will be treated confidentially and maintained separately from the employee’s personnel file. A detailed explanation of the rights and obligations of employees under the ADA is contained in The Americans with Disabilities Act: Your Employment Rights as an Individual with a Disability , which is available from your State ADA Coordinator’s Office in the Department of Labor and Workforce Development. You may also contact MAA’s Benefits department for more information. In order to complete this form, you will need to discuss the essential functions of your job with your supervisor. You may also contact the Benefits department if you have questions or need information about the ADA or the process for requesting reasonable accommodation. Employee Information Name: _______________________________________ Telephone#: __________________________ Job Title: _________________________________ Dept./Property: __________________________ Region: ______________________________ Supervisor: __________________________________
1. Please identify your physical or mental limitation(s) and expected duration of limitation(s). It is not necessary to indicate medical diagnosis or condition.
2. Describe the specific accommodation(s) are you requesting and how it will assist you?
a. If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore? Yes No
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3. Describe how your condition limits your ability to perform one or more of the essential functions of your job or interferes with your ability to access employment benefits.
4. Provide any other information or suggestion that may be useful in processing your request for accommodation(s).
_____________________________________________________________ Employee Name (Please print)
______________________________________________ _____________________________ Signature Date
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MAA AMERICANS WITH DISABILITIES ACT (ADA) REASONABLE ACCOMMODATION REQUEST Health Care Provider Documentation in Support of the Request
Date:________________________________
Employee’s Name: ___________________________________
Position Held:_______________________________________
________________________________ , who is an employee of MAA, has requested a reasonable accommodation under the Americans with Disabilities ADA (ADA). Attached to this form is the current job description of the essential functions of the position, including the physical and mental demands of the job. Please answer the following questions regarding the employee’s condition solely as it relates to the essential functions and possible accommodations. ** The employee’s signed Release is also attached. 1. Solely with respect to the impairment for which the employee has requested a workplace accommodation, does the employee’s condition constitute a disability that substantially limits a major life activity? Yes No NOTE: An impairment is a disability if it substantially limits the ability of an individual to perform a major life activity as compared to most people in the general population. “Substantially limits” is to be determined broadly. An impairment need not prevent or significantly or severely restrict the individual’s ability to perform a major life activity. Impairments lasting fewer than six (6) months can be substantially limiting. An impairment that is episodic or in remission is a disability if it would substantially limit a major life activity when active.
If yes , what major life activity(s) is/are affected?
Bending Breathing
Hearing Interacting With Others Learning Lifting Performing Manual Tasks
Reaching Reading Seeing Sitting Sleeping
Speaking Standing Thinking Walking Working
Other: (describe)
Caring For Self Concentrating Eating
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If yes , what major bodily function(s) is/are affected?
Bladder Bowel Brain Cardiovascular Circulatory
Digestive Endocrine Genitourinary Hemic Immune
Lymphatic Musculoskeletal Neurological
Reproductive Respiratory Special Sense Organs & Skin Other: (describe)
Normal Cell Growth Operation of an Organ
2. Does the employee’s condition for which he/she has requested a workplace accommodation affect the employee’s ability to perform any one of the essential functions of the position, which are identified in the job description? Yes No If yes, please describe the impact on the person’s ability to perform specific functions.
3. Are there any accommodations that, in your opinion, would allow the employee to perform the essential functions of the job? Yes No If yes, please describe those accommodations, including frequency, duration, or time period of flare-ups; anticipated length of time that accommodation will be needed and anticipated frequency that accommodation will be needed; and frequency, number and schedule of anticipated follow-up treatment appointments.
4. If the employee cannot perform the essential functions of this position with or without an accommodation, what type of work, if any, can the employee perform with or without an accommodation? Please be specific.
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5. Is the need for accommodation likely to be temporary or permanent? If temporary, how long do you estimate the need for accommodation will exist?
6. Does the employee take any prescription medication that may limit his ability to perform his job or the suggested accommodation? If so, identify the restrictions or limitations based upon the medication(s).
__________________________________________
__________________________________ Professional license or specialty
Provider name (Please print)
___________________________________
__________________________________
Signature
Date
*** The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information’ as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
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EMPLOYEE’S AUTHORIZATION RELEASE
For employee to complete:
I authorize (name of physician) ______________________________________________ or any other physicians involved in my care to release information to my employer regarding my physical (or mental) condition solely relating to my request for an accommodation under ADA. The information disclosed on this form shall only be used for the purpose of determining my ability to perform the essential functions of my job and whether or not the requested accommodation is reasonable.
_______________________________________
______________________
Employee’s Signature
Date
Internal Use Only Date Received: __________________
Received By: ___________________________________
Accommodation Requested is: Approved Denied Modified
If modified describe modification and give rationale.
If denied, give rationale.
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