UNC System Office ADA Accommodation Request

UNC System Office ADA Accommodation Request

Request Guidelines

Consistent with the federal Americans with Disabilities Act Amendments Act (ADAAA), the University of North Carolina System Office (System Office) provides reasonable accommodations to qualified employees with disabilities, as well as visitors and program participants. The System Office Human Resources Division (HR) is charged with determining reasonable accommodations under the ADA and with facilitating the provision of those accommodations.

Having a medical condition alone may not be sufficient to make someone eligible for accommodations under the ADA. Under the ADA, an individual with a disability who may be eligible for accommodations is someone with a physical or mental impairment that substantially limits one or more major life activities or someone who has a record of such an impairment. Substantially limited in performing a major life activity means limited as compared to most people in the general population. Under the ADA, disabilities include, but are not limited to:

Deafness
Blindness
Diabetes
Cancer
Epilepsy
Intellectual disabilities
Partially or completely missing limbs
Mobility impairments requiring the use of a wheelchair
Autism
Cerebral palsy
HIV
Multiple sclerosis
Muscular dystrophy
Major depressive disorder
Bipolar disorder
Post-traumatic stress disorder
Obsessive-compulsive disorder
Schizophrenia

Additionally, accommodations for individuals with medical conditions that put them at more significant risk of severe illness from COVID-19 may be appropriate. However, HR will evaluate these requests individually based on the particular risk posed in the specific working environment.

By initiating the employee accommodation process and completing this request form, you give the System Office permission to explore employment-related reasonable accommodations. All information requested 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 all applicable state and federal laws, or under the provisions of any similar and appropriate sections of succeeding ADA laws. ADA-related medical files are kept separate from personnel files, and access is limited to personnel involved in the determination of reasonable accommodations.

By considering this request, the System Office does not consider or regard the person as having a disability as defined by the ADA, or any other applicable law. The personnel involved in evaluating an accommodation request are not covered entities as defined in the HIPAA rules. With certain exceptions, HR will not disclose the diagnostic or treatment information of its employees participating in the accommodation process. There are, however, instances when your information is shared with certain individuals such as other human resource personnel, first aid and safety personnel, or System Office personnel investigating compliance with the ADA.

Form Instructions

This form is for System Office employees, visitors, and program participants who are requesting reasonable accommodations. Provide a response to each field below.

Please select the most appropriate category.*

System Office employee

Visitor or program participant (including interviews for open positions)

First Name*

Last Name*

Preferred Name

Pronouns

Position/Job Title*

Division*

Select

Employee Type*

Select

Employment Status*

Select

Email Address*

If you are a System Office employee, please use your work email.

Preferred Contact Phone Number*

Phone

Supervisor Name*

Supervisor Email*

Current Work Schedule*

Do you have limitations that may affect your ability to evacuate during an emergency?*

Yes

Not sure

Please describe the affect this may have on your ability to evacuate.

Is your disability*

Temporary (typically less than six months in duration)

Permanent (typically more than six months)

Unknown (needs further evaluation)

What is your disability?*

Briefly describe your essential job functions or job responsibilities.*

Describe the limitations and/or restrictions experienced at work that are caused by your disability.*

Describe the limitations and/or restrictions experienced onsite that are caused by your disability.

List any accommodation(s) or service(s) related to your disability that would help you to meet the essential functions of your current job.*

List any accommodation(s) or service(s) related to your disability that would help you to meet the essential functions of your visit to our facility.

Have you received accommodations at the System Office in the past?*

Yes

What were they?

Accommodation Types

Additional Leave

Are you currently on Family Medical Leave (FMLA) or other medical leave?*

Yes

When does your medical leave end?

Are you requesting additional leave as an accommodation?*

Yes

What is your requested return to work date?

Have you exhausted your FMLA?

Select

Remote Work

Are you requesting remote work (full- or part-time) as an accommodation?*

Yes

Have you been approved for a flexible work location through the System Office Flexible Work Accommodations policy?

Yes

What is your flexible work schedule?

If you have not been approved for a flexible work location through the System Office request process, and you are eligible for a flexible work location based on your job responsibilities, you should work first with your supervisor to request a flexible work location. If your flexible work request was denied, attach your completed form or other explanation in the File Upload box at the bottom of this form.

Certifications

By submitting this request, you agree to the following:

You must submit the Documentation of Disability form, completed by a health care provider, to System Office HR before the interactive accommodations process can begin. You are responsible for ensuring that your health care provider provides sufficient information to System Office HR to evaluate the medical necessity for accommodations.*

System Office HR is permitted to share relevant information from your physician or other health care provider(s) related to workplace limitations with the supervisor(s) in your immediate work unit and other System Office divisions that may be involved in assisting in the development of reasonable accommodations to assist you in completing your assigned work-related responsibilities.*

System Office HR has your permission to contact your physician or other health care provider(s) for additional information to assist in developing reasonable accommodations for you.*

Use the box below to upload any documents relevant to your request.

Drag and drop files here or

Send me a copy of my responses

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