OCCUPATIONAL MEDICAL SERVICES (OMS)
EMPLOYEE REASONABLE ACCOMMODATION REQUEST FORM
This form is to be completed by employees when requesting an accommodation or modification to a prior
accommodation under the American’s with Disabilities Act (ADA). Your Health Care Provider will be required to
complete the ADA Medical Questionnaire which will be used to assist the County Employee Medical Examiner in
evaluating your medical condition.
PART I:
EMPLOYEE REQUEST
(To be completed by employee and forwarded to Disability Program Manager)
NAME:
TELEPHONE: ___________________________
DEPARTMENT: _______________
POSITION:
___________________________
SUPERVISOR: __________________
SUPERVISOR TELEPHONE: ________________
ACCOMMODATION REQUESTED:
NOTE:
The ADA does not require that a specific or requested accommodation be granted but rather that an appropriate
reasonable accommodation be made to a qualified individual with a disability. The County will make all efforts to reasonably
accommodate the employee in his/her current position before exploring alternative placement.
PART II:
TO BE COMPETED BY OMS:
Date request received: ___/___/___
Date of Intake Interview Conducted by Disability Program Manager (DPM):
Date medical information received: ______
If you are a MCGEO collective bargaining unit employee, do you want the union to receive a
copy of this request
? ______________
PART III:
TO BE COMPLETED BY SUPERVISOR
Department is able to provide accommodation: ___Yes ___ No
If No, Please provide information as to why accommodation can not be granted.
Suggested Alternative Accommodation:
Supervisor Signature:______________________________ Date:__________________
Department is responsible for accommodations under $500.00. OHR will share expenses on accommodations
greater than $500.00.
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