Appendix A

Reasonable Accommodation Request Form
This form must be completed by an employee requesting reasonable accommodation(s) under
the American with Disabilities Act of 1990 (“ADA”), Pennsylvania Human Resources Act, and
Pennsylvania Western University policies. Completed forms are to be returned to the Office of
Equity and Title IX].
1. NAME

2. DATE OF REQUEST

3. JOB/POSITION TITLE

4. DAYTIME TELEPHONE NO.

5. DEPARTMENT NAME/ADDRESS

6. EMAIL ADDRESS

7. SUPERVISOR’S NAME

8. SUPERVISOR’S TELEPHONE NO.

Please answer the following questions to assist the University in understanding the basis and
nature of your request for an accommodation. The information you provide will be treated
confidentially and will be handled on a need-to-know basis.
1.
Identify the physical and/or mental impairment(s) for which you are requesting
accommodation and the expected duration of the accommodation.

2.
Explain how the impairment(s) listed above affect(s) your ability to perform the
essential functions of your position or access employment benefits. Be as specific as
possible regarding the job duties you are having difficulty performing or believe you will
have difficulty performing.

3.
Describe any type of accommodation which you believe will enable you to
perform the function of the position or access employment benefits.

4.
Describe how this accommodation will assist you in performing the function of the
position or access to employment benefits.

5.
If you have had any accommodation in the past for this same limitation, describe
those accommodations and how effective they were.

6.
Do you have documentation to support your disability? YES _____ NO _____ If
YES, please attach. [Documentation includes statements or other documentation from a
physician or other professional identifying the disability and addressing what, if any,
accommodations are necessary based upon your job duties. [See Medical Certification
Form for additional information]. If you need a copy of a job description to provide to your
medical professional, please contact the Office of Human Resources, Dixon Hall, 250
University Avenue, California PA, 15439, guiser@pennwest.edu, 724-938-4427.
Acknowledgement
I understand that it is my responsibility to complete the attached Release of Medical Information
Statement and to provide a Medical Certification Statement to the Office of Equity and Title IX
for my request to be evaluated. I further understand that the Office of Equity and Title IX will
evaluate and respond to me based upon the information that I provide.
SIGNATURE

DATE

RECEIVED BY EQUITY and TITLE IX

DATE

Information or assistance regarding accommodation requests can be obtained by contacting
the- Office of Equity and Title IX, asalsgiver@pennwest.edu, 423 Becht Hall Clarion Campus,
814-393-2109.

Release of Medical Information Statement
I, _____________________________, understand that I am giving permission to Pennsylvania
Western University of Pennsylvania Office of Equity and Title IX to contact the following
individual(s) for purposes of requesting documentation/information regarding my disability
including the diagnosis and limitations associated with that diagnosis. I understand that this
permission will remain in effect from the day I sign this document until I revoke permission in
writing or am no longer affiliated with Pennsylvania Western University of Pennsylvania.
Name

________________________________________________________________

Address

________________________________________________________________
________________________________________________________________

Phone

_______________________ E-mail ___________________________________

Name

________________________________________________________________

Address

________________________________________________________________
________________________________________________________________

Phone

_______________________ E-mail ___________________________________

I understand that communication with the above-named individual(s) will not include personal
disclosures that do not pertain to my identified disability(ies). I understand that all medical
information related to my request for accommodation is confidential and will be maintained in a
secured location within the Office of Equity and Title IX separate and apart from my personnel
file. I further understand that I will be required to provide the complete Medical Certification
Form, attached, including the impact of functional limitations on my ability to perform the
essential functions of my job.
SIGNATURE

DATE

RECEIVED BY EQUITY and TITLE IX

DATE

Medical Certification Form
Note: The information sought on this form pertains only to the condition for which the employee
is requesting accommodation under the Americans with Disabilities Act (“ADA”).
To be completed by Employee
1. NAME

2. JOB POSITION/TITLE

3. SIGNATURE

4. DATE

To be completed by Health Care Provider
The employee listed, above, is an employee of Pennsylvania Western University of
Pennsylvania. The employee has requested an accommodation for a disability and has
identified you as their health care provider. The employee claims to have the following
condition(s):

and that this condition(s) requires an accommodation to enable them to perform the essential
functions of their job. To assist the University in evaluating this request for accommodation,
please provide detailed answers to the following questions, using additional sheets where
necessary. The information you provide will be considered confidential and used only to
evaluate the employee’s request for accommodation.
Please return the completed form to Office of Equity and Title IX, asalsgiver@pennwest.edu,
423 Becht Hall Clarion Campus.
Please Note: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits
employers and other entities covered by GINA Title II from requesting or requiring
genetic information of an individual or family member of the individual, except as
specifically allowed by law. To comply with this law, we are asking that you not provide
any genetic information when responding to this request for medical information.
‘Genetic Information’ as defined by GINA includes an individual’s family medical history,
the results of an individual’s or family member’s genetic tests, the fact that an individual
or an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual’s family member or an
embryo lawfully held by an individual or family member receiving assistive reproductive
services.

For reasonable accommodation under the ADA, an employee has a disability if the employee
has an impairment that substantially limits one or more major life activities or a record of such
an impairment.
1.

Have you examined the employee for the above-stated condition? Yes _____ No ______
Date of examination(s): ___________________________________________________

2.

Does the employee have a “physical or mental impairment?” Yes ______ No ______

3.

If you answered “yes” to question 2, please identify the employee’s specific physical or
mental impairment (diagnosis):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

4.

Does the above-identified impairment substantially limit a major life activity of the
employee?
Yes_______ No_______

5.

If you answered “yes” to question 4, please describe what major life activity(ies) is
substantially limited.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

6.

Please describe the manner and extent to which the impairment limits the above described
major life activity(ies).
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

7.

What is your prognosis for whether and in what manner the impairment will continue to
limit the above-described major life activity(ies)?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

8.

What is the expected duration of the impairment?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

9.

How does the impairment affect the employee’s ability to perform the essential functions
of the employee’s job? (See attached job description). Please be specific.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

10.

Please provide any additional medical information or documentation that you believe will
assist the University in evaluating the impact of the employee’s impairment; the activity or
activities the impairment limits; and the extent to which the impairment limits the
employee’s ability to perform the activity or activities.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

11.

Please list any accommodation(s) you believe would enable the employee to perform the
essential functions of the employee’s job.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Thank you for completing this Medical Certification Form. The University will use the
information you have provided to evaluate the employee’s request for accommodation.
1. PHYSICIAN’S SIGNATURE

2. DATE

3. PHYSICIAN’S NAME

4. TELEPHONE NUMBER