However, they may be a useful tool for both employers and employees. identified on this request form, and any related medical restrictions and. The use of these forms does not insulate a user from liability or create a presumption that discrimination did not occur. reasonable accommodation can be made without causing undue hardship to. The following person in my household has a disability: Name First Name Last Name. This statement must be provided to or via mail or fax.
MEDICAL REASONABLE ACCOMMODATION REQUEST FORM PROFESSIONAL
The law does not require the use of these or any other forms to make a request for a reasonable accommodation or to engage in an effective, good faith interactive process. To complete your request you must provide a statement on letterhead from your licensed professional pertaining to your request. The DFEH has created a sample Request for Reasonable Accommodation package to assist employers and employees in engaging in the interactive process. Please describe any potential reasonable accommodation that would overcome the above limitations. The process requires an individualized assessment of both the job and the specific physical or mental limitations of the individual that are directly related to the need for reasonable accommodation. (Attach medical documentation) Specify which of you major life activities are limited by your disability. You are protected from retaliation for making this request. Your cooperation is essential in order to ensure a productive, interactive process with the goal of finding an acceptable accommodation. The point of the process is to remove barriers that keep people from performing jobs that they could do with some form of accommodation. The Request for Reasonable Accommodation form allows you to state what accommodation you need and why you need it, and has a release for the BHA to speak with your medical professional or qualified service provider (for example a social worker or case worker). Provider Accommodation Assessment Form to support your request. In California, it is unlawful for an employer to fail to engage in a timely, good faith, interactive process. This awareness might come through a third party, by observation, or because the employee has exhausted leave benefits but still needs reasonable accommodation. The employer must also offer to initiate an interactive process when the employer becomes aware of the possible need for an accommodation.
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The California Fair Employment and Housing Act requires employers of five or more employees to provide reasonable accommodation for individuals with a physical or mental disability to apply for jobs and to perform the essential functions of their jobs unless it would cause an undue hardship. Navy’s Reasonable Accommodation Request Form.