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ADA Form 1
ADA REASONABLE ACCOMMODATION REQUEST
To be eligible for a reasonable accommodation under the Americans with Disabilities Act (ADA), you must (1) be able to perform the
essential functions of your position with or without a reasonable accommodation and (2) have a disability as defined in the ADA that
substantially limits a major life function.
Employee Information
Name:
Job Title:
Department/Location:
Employee ID Number:
Daytime Phone Number:
Name of your Supervisor:
1. Describe the accommodation you are requesting.
2. Explain how the accommodations you are requesting will enable you to perform the essential functions of your job. Be
specific.
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ADA Form 3
ADA Release of Information
I authorize my medical provider(s) to release information to, and if necessary, speak with the Newport News Public Schools Human
Resources Office about my medical condition for the purpose of determining appropriate job accommodation(s) for my condition.
Physician Name:
Physician Address:
Physician Fax number:
Employee Name:
(Print)
Date:
Employee Signature:
Please submit the completed form to:
(Fax)
757-643-7405
(Office)
12507 Warwick Boulevard
Newport News, VA 23606Jump to an indexed page (1 of 1)