Employee Request Form

Equal Opportunity and Access Division Employee Reasonable Accommodation Request Form The Minnesota Department of Human Services (DHS) is committed to complying with the Americans with Disabilities Act (ADA). If you think you have a disability and need a reasonable accommodation to do your job, please complete and return this form. If you need assistance with your request or have questions about the process, please contact us.

Your Information

First Name Last Name Employee ID Position Division Work Phone Work Email Work Location Union & Local Supervisor Name

Data Privacy Statement

Your information may be used by ADA staff, Human Resources, legal counsel, or any other individual whom DHS authorizes to receive medical information to comply with the ADA. This information is necessary to determine whether you have a disability and whether you may receive any reasonable accommodation under the ADA. Your provision of the information is strictly voluntary; however, if you do not provide it, DHS may not have sufficient information to make a reasonable accommodation for you.

Accommodations Requested

Describe your impairment(s) that needs reasonable accommodation(s) Describe your difficulty with any application process, job function(s), or employment benefit(s) because of your impairment(s) Add any other information that may assist in processing your request Please select any reasonable accommodation(s) that may lessen that difficulty Arrangement for Accessible Parking Alteration of Available facilities to be physically accessible and Usable Adjustment to Hiring Process Adjustment to Testing of Training Modification of Policy, Procedure, Rule or Practice Provision of Alternative Devices, Adaptive Equipment, or Assistive Technology Provision of Qualified Reader, Writer, Sign Language Interpreter, or Other Assistant Restructuring of the Job Provision of Alternative Work Area Approval of Extended Leave of Absence Reassign to Lateral/Demotional Vacant Job that Minimally Qualified & Within Stable Work Restrictions Permission for Modified or Part-Time Work Schedule Describe in detail the accommodation(s) you're requesting

Medical Information Notice

In processing your request for reasonable accommodation, the ADA staff may ask you to provide medical information to determine your bodily limitations and any reasonable accommodation. If necessary, you may either complete a medical information release authorization and provide medical documentation supporting your request or have your medical professional complete a medical information request. The return of these forms is your responsibility. This request does not cover, and the information to be disclosed should not contain, genetic information. “Genetic Information” includes: information about an individual’s genetic tests; information about genetic tests of an individual’s family members; information about the manifestation of a disease or disorder in an individual’s family members (family medical history); an individual’s request for, or receipt of, genetic services, or the participation in clinical research that includes genetic services by the individual or a family member of the individual; and genetic information of a fetus carried by an individual or by a pregnant woman who is a family member of the individual and the genetic information of any embryo legally held by the individual or family member using an assisted reproductive technology. Medical Document Authorization Document

Electronic Signature

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Record Information

From Address* Subject