EMPLOYEE REQUEST FOR ACCOMMODATION

The Company endorses and complies with the Americans with Disabilities Act (ADA) and amendments, and the Utah Antidiscrimination Act, as well as other similar local and state laws. Consistent with the ADA and Utah law, the Company provides reasonable accommodation to the known physical or mental limitations of a qualified employee with a disability, unless doing so would impose an undue hardship or create a direct threat of harm to the employee or others. [1]

If you believe you may need accommodation to enable you to perform essential job functions and/or to allow equal access to the benefits and privileges of employment that non-disabled employees enjoy, you may request accommodation by completing this form and submitting it to Human Resources.

In this form the Company asks you what accommodation you are requesting (or believe you may need) and the reason that you believe you need accommodation. After reviewing your request, the Company will engage with you in an interactive dialogue about your request. Where needed, the Company will ask you to obtain and provide relevant supporting medical information from your treating health care provider and/or the Company may request an IME. This medical information, which will help with the interactive dialogue, will be kept confidential consistent with applicable law and will be used only as needed to evaluate, process and, if appropriate, implement your request.[2]

Providing requested information is voluntary. The purpose for requesting information is to facilitate assessment of the request for accommodation. If you decline to provide the requested information, the Company will be forced evaluate your request with the information that is available. This may result in the request being denied if there is not enough information to support it.

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Name *

Job Title *

Date *

Location *

1. If you believe you may need accommodation enable performance of any functions of your current position, please identify and describe those functions for which you believe accommodation is needed. Where possible, please refer to your job description. [3] *

2. If you believe you may need accommodation allow equal access to the benefits and privileges of employment that non-disabled employees enjoy, please identify and describe those benefits and privileges for which you believe accommodation is needed. *

3. Identify and describe the physical or mental disability, illness, condition, or disease that is the basis for your request for an accommodation. *

4. Describe how the requested accommodation(s) will assist you. *

5. Identify and describe any equipment or technology that you are requesting (the more specific the better, but we understand that sometimes only general information is known). *

6. Should medical information relevant to your request be needed, here is the name, phone number and address of my healthcare provider treating me the condition identified above. *

Certification *

I certify that I have read this form and that the foregoing statements are complete, accurate, and true to the best of my knowledge. I understand that intentionally false or misleading statements may be cause for corrective action, up to and including termination.

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Date *

[1] Accommodations may take many forms including modifications: (a) to the work environment (e.g., a special chair, a raised desk, etc.); (b) to the manner/circumstances under which the job is commonly performed (e.g., a change in schedule, reassignment to a different job, extensions of leave, changes to marginal functions, etc.); and (c) that enable the enjoyment of equal benefits and privileges (e.g., repositioning a vending machine to an area accessible wheelchair users). The reasonableness of any requested accommodation is evaluated on a case-by-case basis.

[2] Note: Where two or more accommodations would be reasonable, the Company may select the reasonable accommodation to be provided; it may select a reasonable accommodation different than the one you request.

[3] There are no magic words that you need to use. Just describe it the requested accommodation as best you can.