ADA Reasonable Accommodation Request Form
The Americans with Disabilities Act (ADA), the Americans with Disabilities Amendments Act (ADAAA) and Section 504 of the Rehabilitation Act of 1973 are federal laws that protect applicants and individuals with disabilities from discrimination. Under this legislation, employers are requested to address accessibility issues for people with disabilities, and the right to obtain equal access to services, programs, buildings, facilities, and employment.
Disclosing My Mental Health Condition at Work
Employee's Full Legal Name
*
First Name
Last Name
Employee's CPR Email Address
*
example@example.com
Employee's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your position / title at CPR?
*
Have you notified your direct Supervisor / Manager of your need for accommodation?
*
Yes
No
Do you know what specific accommodation you are requesting?
*
Yes
No
What accommodation are you requesting?
*
What is the nature of your request?
*
Is your accommodation request time sensitive?
*
Yes
No
What job function are you having difficulty performing and what limitation is interfering with your ability to perform your job?
*
Have you had any accommodations in the past for this same limitation?
*
Yes
No
What were the past accommodations and how effective were they?
*
How do you feel this accommodation will improve your day-to-day?
*
Please confirm you are aware HR may require a medical certification from your treating provider.
*
I confirm.
Submit
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