ADA Disability Accommodation Form

The University of Oregon recognizes that disability is a critical component of diversity in the workplace. More information about the process can be found in our Workplace Accommodation eLearning module.


The Accommodations Coordinator is responsible for administering the interactive process for university employees to request workplace accommodations. Each request is assessed on an individual basis.


As an initial step in the accommodation process, please answer the questions on this request form. This information will help the Accommodations Coordinator understand how your disability or medical condition impacts you in the workplace and what accommodations you believe would help address your needs.


Next, the employee requesting an accommodation will be asked to have their healthcare provider complete the university’s Medical Provider Form and submit it to the Accommodations Coordinator. The Medical Provider Form is narrowly tailored to help ensure receipt of limited information necessary to assess an employee’s eligibility for workplace accommodations.


To designate a support person, you must complete a Support Person Authorization form and upload to this form.


Please contact workplaceADA@uoregon.edu with questions.

 
 
 
 

If you are a job applicant or member of the public, put N/A.

 

If you are a job applicant or member of the public, put N/A.

 

If you are a job applicant or member of the public, put N/A.

 

If you are a job applicant or member of the public, put N/A.

 
 
 
Phone
 
 
 
 

Is your need for a workplace accommodation urgent?

 

Please describe how your disability or medical condition impacts your ability to perform the functions of your job or employment.

 
 

Please identify, in as much detail as possible, the workplace accommodation or accommodations that you believe would help enable you to effectively perform the functions of your job or otherwise enjoy an equal employment opportunity.


For ideas of accommodations that might be useful to you, visit AskJAN.org.

 
 
 

Please provide any additional information that you believe is relevant to your request for accommodation.

 
 

Do you have Long Term Disability insurance as part of your UO employee benefits?


If so, you may be eligible for support through The Standard's Workplace Possibilities Program, which provides Stay-at-Work resources for employees.

 

If available, please upload your completed Medical Provider form and/or your Support Person Authorization form. Uploading these documents will make evaluation of your accommodation request more efficient.

Drop your files here
 

I certify that I am submitting this form on behalf of myself or as a support person for another, and that to the best of my knowledge the information provided in this form is true and accurate.