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Escondido Union ESD |  E  4032  Personnel

Reasonable Accommodation   

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Request For Reasonable Accommodation Form

________________________________________________________________________

Name: ___________________________________________

Job Title: _________________________________________Date: ____________

1. In functional terms, please describe the extent, nature and severity, and permanent or long-term impact of your medical condition. If the condition is temporary, please describe its expected duration.

2. Please list any restrictions that arise from your medical condition that would restrict your ability to perform your job duties. Please attach your job description.

3. Please describe in writing any specific limitations on your ability to perform each essential function, and what specific accommodations may exist that would allow you to perform effectively any essential functions affected by your limitations. (We require as much detail about specific limitations and accommodations as you can provide so that we can determine whether or not a particular accommodation or group of accommodations is reasonable and necessary.)

4. If you know of no accommodations that would enable you to perform all of the essential functions of the job, please inform us so that we may pursue other possible sources of information on this point.

5. If there are medical records which document your disability and/or support your request for accommodation, please attach them to this form.

(If more space is needed, please attach additional pages to this form.)

Return all information to the Deputy Superintendent, Human Resources

Exhibit ESCONDIDO UNION SCHOOL DISTRICT

version: April 2006 Escondido, California