C.E.F.S. Economic Opportunity Corporation

Reasonable Accommodation Request for Applicants

Pursuant to the requirements of state and federal laws, a qualified individual with a disability has the right to request reasonable accommodation in conjunction with his or her employment. Reasonable accommodation means a modification to the application procedure, access to the work site, and adjustment to the work process or work schedule that would enable a person with a disability to perform a particular job. Employers are not required to provide accommodations that would impose undue hardship on the operations of their programs. Completed accommodation request forms should be submitted to the appropriate Program Director. The agency’s EO/AA Officer can respond to questions about the accommodation process.

 

Name: __________________________________

Interviewing Agency: ___________________________

Home Address: __________________________________________________________________________

Phone Number: __________________________

Functional Limitations: __________________________

 

 

Type of Accommodation Needed:

 

 

 

• Sign Language Interpreter for the Employment Interview

• Reader Service

• Accessible Interviewing Site

• Re-formatting of Examinations for Learning Disabled Applicant

• Examination Markers for Applicants with Limited Manual Dexterity

• Other (indicate type of accommodation needed) ________________________________________

• ​

 

 

Narrative Explanation

 

Describe how your functional limitation interferes with the performance of a duty or participation in an activity sponsored by the employer. Explain how the requested accommodation would be used to enhance job performance or would allow you to participate in an employer-sponsored activity. (Use additional sheets if necessary)

 

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

 

Applicant’s Signature: _________________________________________

Date: ____________________

 

 

 

 

Agency Action

 

 

 

Program Director’s Determination

• Grant

• Deny

Initial/Date: ____________________

 

 

 

 

Remarks

_______________________________________________________________________________________

_______________________________________________________________________________________

Final Agency Approval

COO Signature: ____________________________________________

Date: ______________________