ADA Request Form

ADA Accommodation Request Form

Tatum Independent School District

510 Crystal Farms Rd., Tatum, TX

An employee with a disability that creates work-related limitations is responsible for making the employer aware of their need and disclosing the nature of their disability. This form may be used to request an adjustment for a reason related to a physical or mental condition.

Name

Date of Request

Date

Position*

Department/campus*

Describe the reason you need an accommodation including the limitations or restrictions imposed by your disability.

Identify the job functions you are having trouble performing.

Describe how your limitations affect your ability to access a benefit of employment.

Describe the accommodation you are requesting and how it would help you perform the essential functions of your job.

Employee signature

Date

*This form and all medical information must be kept confidential and filed separately from the main personnel file. The employee's supervisor may be informed about necessary restrictions on the work or duties and necessary accommodations. When appropriate, first aid and safety personnel may be informed if the employee's disability might require emergency treatment or if any specific procedures are needed in case of fire or other evacuations.