LAC 22:I.203 – Request for Accommodation

CONFIDENTIALITY STATEMENT:A request for accommodation, including medical and other relevant information, is privileged and may only be released as appropriate to individuals with a business need to know.CONFIDENTIALITY STATEMENT:A request for accommodation, including medical and other relevant information, is privileged and may only be released as appropriate to individuals with a business need to know.REQUEST FOR ACCOMMODATION FORM

SECTION 1: REQUESTOR INFORMATION

Requestor’s Name:__________________________________________

Requestor is (check only one): Employee Job Applicant Visitor / Public

Requestor’s Email Address: _____________________________________________________________

Requestor’s Phone #: ________________________________

If Requestor is an employee, also provide: Job Title: _________________________________________

Division/Unit:________________________ Supervisor’s Name: _________________________________

SECTION 2: REQUESTED ACCOMMODATION (Attach a separate sheet if additional space is needed)

A. Please describe the nature of your disability and the functional limitations resulting therefrom.

_______________________________________________________________________________________

B. Check the type of accommodation requested. Use the blank space provided to the right to further explain reason for the requested accommodation.

	Accommodation Type:	Reason for Accommodation Request:
1.	Application/Testing Process Explain the specific application/testing requirement for which accommodation is requested: ()
2.	Participating in a Job Interview Identify the Date/Time/Location of the job interview for which an accommodation is requested: ()
3.	Performance of Essential Functions of Your Job Explain the job duties for which accommodation is requested: ()
4.	Benefits/Privileges of Employment Explain the benefits or privileges of employment for which accommodation is requested: ()
5.	Pregnancy, Childbirth or Related Condition Explain how pregnancy, childbirth or a related condition affects your ability to perform your job: ()
6.	Effective Communication Identify the Date/Time/Location for which an auxiliary aid is requested: ()
7.	Access to Programs, Services or Facilities Identify the specific program, service or facility for which access is needed: ()

C. Describe the accommodation(s) requested. (Identify specific auxiliary aid requested, if applicable)

_______________________________________________________________________________________

Requestor’s Signature: _________________________________________ Date: ___________________

a. Process Tracking:

1. Date the Request for Accommodation was prepared/signed by Requestor: _____________

2. Date the Request for Accommodation was received by ADA Coordinator: _____________

3. Date of initial contact with Requestor (initiate interactive process): _____________

4. Date(s) of follow-up contact with Requestor: _____________ _____________ ____________

5. Date the Request for Accommodation was discussed with Appointing Authority: ___________

6. If applicable, date the alternative accommodation(s) was discussed with Requestor: ___________

7. Date Requestor was notified of final accommodation determination: _____________

8. Date Requestor was notified of internal grievance procedure: _____________

b. Is there an equally effective accommodation(s), other than the one requested, that would satisfy the request? (Consult with or Louisiana Rehabilitation Services, if necessary) Yes No

If Yes, please identify: _________________________________________________________________

____________________________________________________________________________________

c. Was an accommodation granted? Yes (Proceed to section d. below) No (Proceed to section e. below)

d. Accommodation Granted:

Was the accommodation granted the same as the one requested? Yes No

If an alternative, equally effective accommodation was granted, explain the reason this option was selected rather than the one requested. (Reason for alternative accommodation should be fully documented.)

_______________________________________________________________________________________

e. Denial of Accommodation:

Check reason for denial and provide further explanation below. (Denials should be fully documented.)

ADA Title I (for employees / applicants)
Requestor is not a “qualified individual”
(See Definition in agency policy)
Accommodation would pose an
undue hardship to the agency
Accommodation would not eliminate
direct threat of substantial harm to
safety of individual or others

ADA Title II (for visitor / public)
Requestor is not a “qualified individual”
(See Definition in agency policy)
Accommodation would fundamentally alter the nature of the agency’s service, program or activity
Accommodation would not eliminate direct
threat of substantial harm to safety of individual or others

_______________________________________________________________________________________

ADA Coordinator’s Signature: ________________________________ Date: _____________________

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:225, et seq.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Public Safety and Corrections, Corrections Services, LR 26:1312 (June 2000), amended LR 49:499 (March 2023).