Employee Accommodation Request Form

Employee Accommodation Request Form

The University of Texas at Austin (University) is required by law to provide reasonable accommodations to qualified employees with disabilities in accordance with the Americans with Disabilities Act, as amended (ADA) and to employees experiencing limitations associated with pregnancy, childbirth, or related conditions under the Pregnant Workers Fairness Act (PWFA). The determination of reasonable accommodations is a collaborative and interactive process between the University ADA Coordinators, the employee seeking accommodations, the employee’s supervisor, and/or other appropriate personnel (e.g., Human Resources or Leave Management) as needed.


Eligibility under the ADA


The University ADA Coordinators are charged with coordinating the University’s compliance with the ADA. University employees with a qualifying condition are evaluated for workplace accommodations under Title I of the ADA. Having a medical condition alone is not enough to make someone eligible for accommodation under the ADA. Under the ADA, an individual with a disability is someone with a physical or mental impairment that substantially limits one or more major life activities, has a record of such an impairment, or is regarded as having such an impairment. To have an “actual” disability (or to have a “record of” a disability) an individual must be (or have been) substantially limited in performing a major life activity as compared to most people in the general population. Documentation from an individual’s healthcare provider is necessary to assess the functional limitations associated with one’s disability and what accommodations are appropriate. ADA related medical files are kept separate and apart from the location of personnel files, and access is limited to those personnel involved in the implementation of workplace accommodations.


Eligibility under the PWFA


The PWFA requires employers to provide reasonable accommodations to a worker’s known limitations related to pregnancy, childbirth, or related medical conditions. While most accommodations under the PWFA can be managed at the departmental level, the ADA Coordinators are available to facilitate the process when situations are more complex. Documentation from an individual’s healthcare provider is necessary in these situations to assess the limitations associated with one’s condition(s) and what accommodations are appropriate.


By initiating the employee accommodation process and completing the request form below, you give The University of Texas at Austin permission to explore employment related reasonable accommodations. All information obtained from medical examinations and inquiries will be job-related and consistent with business necessity and will be maintained and used in accordance with the ADA and/or PWFA, and all applicable state and federal laws. By considering this request, the University does not consider or regard the person as having a disability as defined by the ADA, or any other applicable law. The ADA Coordinators and personnel involved in evaluating an accommodation request are not covered entities as defined in the Health Insurance Portability and Accountability Act (HIPAA) rules. With certain exceptions, the ADA Coordinators will not disclose the diagnostic or treatment information of its employees participating in the accommodation process. There are, however, instances when information is shared with certain individuals such as human resource personnel, first aid and safety personnel, or University personnel investigating compliance [e.g., University Compliance Services (Title IX, Department of Investigation and Adjudication); Legal Affairs).


Directions: Provide a response to each field below.


Classification*

College, School, or Unit

Select or enter value
Caret IconCaret symbol

(building and suite/office number)

(please also provide their contact information)

Are you applying for accommodation related to pregnancy, childbirth, or a related condition*

Upload a copy of your job description (if available)

Drag and drop files here or