Americans with Disabilities Act (ADA), Section 503 of the Rehabilitation Act and Vietnam Era Veterans' Readjustment

Self Identification and Accommodation Request Form

The Americans with Disabilities Act (ADA), Section 503 of the Rehabilitation Act and Vietnam Era Veterans' Readjustment Assistance Act (VEVRAA), as well as state and local laws require that reasonable accommodations be provided to qualified individuals with disabilities. Disabilities are defined as physical or mental impairments that substantially limit one or more of a person’s major life activities.

Hood College is committed to working with qualified individuals that meet the definition for disability to determine whether or not a reasonable accommodation is necessary and to identify an appropriate and effective accommodation.

A reasonable workplace accommodation is a modification or adjustment to a job’s customary tasks or responsibilities to enable a qualified employee with a disability to perform essential job functions so long as the modification or adjustment does not result in an undue hardship on Hood College. Reasonable workplace accommodation also includes adjustments to assure that a qualified individual with a disability has equal access to employment rights and privileges.

Employee FIrst Name:

Employee Last Name:

Cell Number:

Email:

Division:

Department:

Office Extension:

Office Location

Job Title:

Self-Identification of Disability and Request for Accommodation

1 . Identify your disability or physical or mental impairment(s) or limitation(s) ("Disability") that impacts one or more major life activities:

2 . Explain how your disability impairs or limits your ability to perform the essential functions of your job duties:

3 . Expected duration of the disability:

4 . What specific accommodation(s) are you requesting, if known?

5 . If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore? If yes, please explain or attach information:

6 . Has a health care professional recommended a specific accommodation? Please describe:

7 . Is your accommodation request time sensitive? If yes, please explain:

8 . If you are requesting a specific accommodation(s), how will that accommodation(s) assist you to perform the essential functions of your job?

9 . Have you had any accommodations in the past for this same limitation? If yes, what were they and how did the accommodation(s) help you perform the essential functions of your job?

10 . Please provide any additional information that might be useful in processing your accommodation request. We will set up a time to meet to discuss your request:

I certify that the information is being provided voluntarily and that all the information is true to the best of my knowledge:

Yes

Medical Certification Process

You should send an original document to Runako Allsopp, benefits manager, at benefits@hood.edu or allsopp@hood.edu, who may need you to provide additional information to assist the College in providing the most appropriate solution to the accommodation needed.

Confidentiality of Disability-Related Information

This information will be kept confidential and shared on a need-to-know basis in order to process the reasonable accommodation request. Periodic recertification may be required.