Disability Programs and Resource Center
1600 Holloway Ave, Student Services Building, Room 110,
San Francisco, CA 94132-4046
Phone (415)338-2472 (voice/TDD) Fax (415)338-1041
The following information is needed to make a formal request for a specific employment related accommodation. All requests are treated as Confidential Information and will be considered on a case-by-case basis. Reasonable accommodations are defined as those changes or adaptations necessary for employees with qualifying disabilities to perform essential job functions. As an employer, San Francisco State University is ultimately responsible for determining the reasonableness of an accommodation, in accordance with provisions contained in the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act as amended, and the Fair Employment and Housing Act (FEHA). Temporary disability such as a sprained wrist or a broken leg may not be considered a qualifying disability.
| Employees's Name:____________________________ |
Position Title:_________________________________ |
| Department:__________________________________ |
Phone Extension:______________________________ |
| Supervisor's Name:____________________________ |
Campus Address:______________________________ |
| Supervisor's Extension:_________________________ |
Campus Email:________________________________ |
Has your disability been verified by a physician, healthcare practitioner, rehabilitation professional, or learning disabilities specialist?
[ ] Yes [ ] No
Type of Reasonable Accomodation Requested:
| [ ] Adaptive Equipment |
[ ] Job Restructuring |
| [ ] Equipment not Normally Provided |
[ ] Leave |
| [ ] Assistive Technology (Hardware/Software) |
[ ] Information in an alternative format |
| [ ] Student Assistant |
[ ] Reader |
| [ ] Interpreter |
[ ] Driver |
| [ ] Modified Work Schedule |
[ ] Parking |
| [ ] Other:_________________________ |
|
Describe the essential job function(s) for which reasonable accommodation is being requested:
If requesting a Student Assistant, please include: Hours per week____ Weeks per year____
Signed:____________________________________________Date:_______________
Please forward any medical or professional verification(s) of disability in an envelope marked "Confidential/Personal" directly to Disability Programs and Resource Center. Contact the DPRC for a confidential consultation.
FOR OFFICE USE ONLY:
| DISABILITY PROGRAMS AND RESOURCE CENTER DETERMINATION |
Finding(s):
| Employee |
[ ] does |
[ ] does not |
have qualifying disability under ADA/FEHA |
| Requested accommodation |
[ ] is |
[ ] is not |
disability related |
| Accommodation |
[ ] is |
[ ] is not |
effective |
| Accommodation |
[ ] is |
[ ] is not |
undue hardship |
ACTION TAKEN:
Rev. 08/03/03