Accommodations may be requested for the following purposes:
1. To complete the employment application process or examination
2. To perform essential job functions
3. To have equivalent benefits and privileges to those available to non-disabled employees
4. To obtain evacuation assistance during an emergency
Advanced notice is usually required to fulfill a request for reasonable accommodation. However, a response to a request for an immediate reasonable accommodation will be accommodated to the extent possible.
Date accommodation is needed:
Check one: ___ Applicant ____Employee
Name: ______________________________ Department: __________________
Job Title: ____________________________ Worksite/Location: _____________
Work Phone: ________________________ Home Phone: __________________
Documentation of Protected Status (disability)—Explain or attach copy:
Please provide the following information:
I am requesting accommodation(s) for the following reason(s): (check all that apply)
___To complete the employment application process, including examination.
___To perform essential job functions.
___To have equivalent benefits and privileges of non-disabled employees.
___To obtain evacuation assistance during an emergency.
How does your limitation restrict your ability to accomplish or obtain the item(s) checked above?
If related to the performance of job responsibilities, state the job functions for which you need an accommodation, and describe the difficulty you have performing that task.
What type of accommodation(s) do you believe would be effective? For those accommodations that must be purchased or attained, please identify possible resources for the county to consider in responding to the accommodation request.
I CERTIFY THAT THE ABOVE STATEMENTS AND ALL INFORMATION PROVIDED ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature: _____________________________ Date: _______________
Submit this form to:
Section 504/ADA Coordinator
2100 Clarendon Boulevard, Suite 318
Arlington, VA 22201
If, after addressing your request, you believe that your rights under the ADA have not been enforced, you may file an appeal with the County Office of Human Rights, EEO and ADA.
For ADA accommodations, questions regarding the ADA, or assistance completing this form please contact Anna Maynard at 703-228-7096 or email@example.com