Checklist: When An Employee Needs Accommodation 

• Does the individual claim to need reasonable accommodation? Yes____ No____ If yes: _________
• Does the person have a current disability? Yes_____ No_____
  • (NOTE: If Individual claims ADA protection only as a result of record of or regarded as coverage, the person is not entitled to reasonable accommodation.) 
• Did the person request reasonable accommodation (i.e., did the person ask for a modification or change because of a medical condition)?(Describe)________________________________________________________________________________________________________
•  In which aspect of employment is reasonable accommodation needed? 
  • Application process
  • Performance of job (including leave)
  • Benefits and privileges of employment
•  What accommodation (if anything specific) was requested?
  • Equipment or Machinery 
  • Reader 
  • Interpreter
  • Modification of Policy (including Leave Policy) 
  • Accessibility 
  • Job Restructuring (Reallocation of Marginal Functions) 
  • Modification to Work Schedule 
  • Examinations/Training Materials 
  • Reassignment
  • Other. Describe accommodation requested:__________________________________________________________________________________________
•  Is the reasonable accommodation needed because of disability? Yes_____ No_____ (Discuss)_______________________________________________________________________________________________________
• Did you engage in an interactive process to identify an effective accommodation? Yes_____ No_____
• Did you discuss accommodation with the individual? Yes_____ No_____If yes, document discussions (include attachments, if necessary)._______________________________________________________________________________________________
• Did you request assistance in determining accommodation from any outside source (e.g., the Job Accommodation Network)?            Yes_____ No_____ If yes, document discussions (include attachments, if necessary).________________________________________________________________________________________________
• Has accommodation been provided? Yes_____ No_____ If yes, is accommodation effective (i.e., does it work?) Yes_____ No_____ (Discuss)____________________________________________________________________________________________________
• Do you claim that providing reasonable accommodation would impose an undue hardship? Yes_____ No_____If yes: What evidence exists to support undue hardship?___________________________________________________________________________________________________________
• Nature and net cost of accommodation (taking into account availability of tax credits and deductions, and/or outside funding)___________________________________________________________________________________________________________
• Overall financial resources of facility/facilities, number of employees at facility, and effect on expenses and resources____________________________________________________________________________________________________
• Overall financial resources of covered entity, overall size of business of covered entity with respect to the number of employees and the number, type and location of facility/facilities_________________________________________________________________________________
• Type of operation(s) of covered entity, including composition, structure, and functions of the workforce of covered entity, and geographical separateness and administrative fiscal relationship of facility/facilities in question to the covered entity________________________________________________________________________________________________________
• Impact of the accommodation on the operation of the facility, including impact on other employees ability to perform duties and facility s ability to conduct business ____________________________________________________________________________________________________________
• Terms of collective bargaining agreement. (Discuss how the accommodation would affect the rights of other employees and whether you tried to negotiate a change to CBA)____________________________________________________________________________________________________________

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