MDUSD Request For Accommodations

MT. DIABLO UNIFIED SCHOOL DISTRICT

Request for Accommodations

First Name*

Last Name*

Work Site*

Position*

FTE (i.e. 1.0)*

Work email*

Confirmation Emailexample@example.com

Cell Phone*

Format: (000) 000-0000.

The ADA prohibits employee disability-related inquiries unless they are job-related and

consistent with business necessity.

Some of the below questions may or may not apply to your specific situation. Please answer each question as best as you can.

Worker's Comp InjuryDisability or Medical Condition

TemporaryShort TermLong TermPermanent

What is your specific request, and is there a medical condition or disability involved in your request?*

YesNo

What's the issue or general condition that you are experiencing that you believe requires you to have an accommodation? (We are not asking for specific information regarding your medical diagnosis, but we do need additional information)*

Precisely how does your condition, disability, or your limitations affect your ability to currently perform your duties?*

YesNo

If yes, what modifications or adjustments to the work environment can be made so that you can continue performing your position's essential functions?*

YesNo

If no, please explain what limitations you are experiencing or believe you will experience.*

YesNoMaybe

YesNo

If no, why not?*

If yes, what?*

YesNo

YesNoNot applicable to my request

YesNoMaybe

Please upload your Medical Note if you currently have one (unless you have already submitted one).