Formal Accommodation Request Form
(New Employees only)

This form is for new employees only. If you have a KU login and employee ID number use this form instead: Formal Request for Workplace Accommodation

Prior to submitting the request for accommodation read KU’s ADA Workplace Accommodation Procedures.

Employees may also choose to review the optional resource, Job Accommodation Network. The Job Accommodation Network website has a variety of resources and information for employees who are making an accommodation request, to include a searchable index designed to let users explore various accommodation options for people with disabilities in work and educational settings. These accommodation ideas are not all inclusive. If you do not find answers to your questions, please contact JAN directly. The staff of experienced consultants is happy to discuss specific accommodation needs in a confidential manner.

You can also contact the ADA Resource Center for Equity and Accessibility with any questions (accommodations@ku.edu). Please see the website information for the

All documents and information related to an employee's medical condition, disability, or illness are treated with strict confidentiality within Human Resources. If you are a student requiring assistance with making an academic accommodation request, please visit S tudent Access Center.

Pregnant Workers Fairness Act

The Pregnant Workers Fairness Act is available to any employee experiencing pregnancy, childbirth, and related medical conditions, including lactation. Provides reasonable workplace accommodations for limitations related to pregnancy, childbirth, and related medical conditions. The below form can be used to request an accommodation pursuant to the Pregnant Workers Fairness Act.

First Name

Last Name

Department

Position Title

Supervisor

Describe your essential job duties

What, if any, job function are you having difficulty performing due to a disability?

Identify and briefly describe the medical condition(s), injury(s) or disability (s) that is affecting your ability to perform your job or access an employment benefit (to include pregnancy, childbirth, or related medical conditions).

Does the medical condition, injury, disability, pregnancy or childbirth substantially limit a major life activity? Major life activities include walking, speaking, breathing, hearing, seeing, thinking sitting, standing, reaching, interactivity with others, learning, etc.

Describe how the condition substantially limits the identified major life activity.

Is the condition temporary or long term? If temporary, how long is the condition expected to last?

Have you had an accommodation in the past for this condition? Describe the previous accommodation. Was this accommodation effective?

Please indicate if you have received an accommodation in the past with our office or type 'None" if you have not

What accommodation are you requesting to perform your essential job duties? Please provide a detailed description of the accommodation requested.

How will this accommodation assist you in performing your job duties?

I have read and agree to the following statements

1. I believe I have a disability that may affect my work. I give Human Resources permission to explore my coverage and reasonable accommodations under the American with Disabilities Act.
2. I understand that submitting this form is an initial step only, and that I may need to meet with Human Resources and possibly provide medical documentation in order to move forward with the accommodation process.
3. I understand that HR must be able to confirm the existence and extent of my disability and how it affects my ability to perform the duties and responsibilities of my position. I understand that this may require me to provide medical documentation and/or authorize contact between my medical provider and HR.
4. I understand that HR will keep medical documentation confidential and will release such medical documentation only in accordance with the American with Disabilities Act or other applicable law. I understand that if I am granted a reasonable accommodation, this may require disclosure of some information about my impairment to supervisors and others at KU who have a need to know enough about the impairment to assist in providing the accommodations and/or in implementing accommodations.
5. I agree to provide all necessary information to process my request. I acknowledge that I have read KU’s ADA Workplace Accommodation Procedures and have had the opportunity to review the optional resources:
Job Accommodation Network
Job Accommodation Network (JAN) Situations and Solutions Finder
6. The statements above are complete, accurate, and true to the best of my knowledge.

Yes

Formal Accommodation Request Form(New Employees only)

Formal Accommodation Request Form
(New Employees only)