ࡱ> MOLM bjbj== ,WWl(((8`t4"tL!!!!!!!$# &z"-"B"F!! c! Џ1j (F c!X"0" & &c! THE EVERGREEN STATE COLLEGE REASONABLE ACCOMMODATION REQUEST FORM NAME _______________________________ JOB CLASSIFICATION _______________________ JOB TITLE __________________________________________________________________________ DIVISION/DEPT ______________________ PHONE NUMBER ____________________________ SUPERVISOR ________________________  DATE OF REQUEST __________________________The purpose of this form is to assist TESC in evaluating reasonable accommodation requests. Return the completed form to Human Resource Services. TO BE COMPLETED BY THE EMPLOYEE: 1) Identify and describe the physical or mental disability which is the basis for your request for reasonable accommodation(s). 2) Which major life activity(s) is substantially limited by this disability? 3) Attach a copy of your current position description. Identify and describe the essential function(s) of your job which you are unable to perform without reasonable accommodation(s). 4) Identify and describe the reasonable accommodation(s) you believe is needed to enable you to perform the essential functions of your job properly and safely, including special equipment, changes in the physical layout of the job or other accommodations. 5) Identify and describe any equipment, aids or services that you are willing to provide and utilize. 6) Identify the names, addresses and telephone numbers of physicians, therapists, psychologists or other health care providers who have information or documentation concerning your disability or your need for a reasonable accommodation. DEFINITIONS DISABILITY includes a physical or mental impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment. MAJOR LIFE ACTIVITIES are those basic activities that the average person in the general population can perform with little or no difficulty. They include functions such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working. ESSENTIAL FUNCTIONS of a position are those fundamental job duties of the employment position - not the marginal functions. Functions may be essential for any of several reasons, for example, if they are the reason the position exists, only a limited number of employees perform them, if they are highly specialized, or the consequences of not performing them are significant. REASONABLE ACCOMMODATION includes modification or adjustment to the job or work environment to enable a qualified individual with a disability to perform the essential functions of the job in question. These definitions are provided only as a guide for completing this form. Nothing in this form is intended to alter the legal definitions of these terms or impose obligations on TESC not required by law. CONFIDENTIAL AUTHORIZATION TO RELEASE MEDICAL INFORMATION I, ____________________________, have requested Reasonable Accommodation from my employer, The Evergreen State College. I hereby authorize the Associate Vice President for Human Resource Service and/or his/her designated representative to receive medical information that will allow my employer to evaluate whether I have a disability and any limitations that affect my ability to enjoy an equal employment opportunity. If this information includes medical information related to mental health issues, alcohol or drug treatment, or sexually transmitted diseases, I specifically authorize release of that information as indicated below: q Mental Health Records (RCW 71.05) q Alcoholism, Intoxication, and Drug Addiction (RCW 70.96A) q Sexually Transmitted Diseases and HIV/AIDS (RCW 70.24) I give permission for the use and disclosure of my confidential medical information solely on a need to know basis and solely for this stated purpose. I understand that I may revoke or discontinue my authorization in writing at any time, and that revocation will not affect any information already shared. A photocopy and/or fax of this release form will be valid as an original, even though the said photocopy and/or fax does not contain an original writing of my signature. This authorization is valid for ninety (90) days from date of signature unless specifically revoked during this time. ___________________________________ Employees Name (Please Print) ___________________________________ _____________________ Employees Signature Date  Office of Human Resource Services Olympia, Washington 98505 (360) 867-5361/FAX (360) 867-6823  HYPERLINK "http://www.evergreen.edu/employment" www.evergreen.edu/employment Page  PAGE 1 of  NUMPAGES 3  DATE \@ "M/d/yyyy" 11/11/2003 DFkl@Bgj,NB C E Q R ^  - 8 M d j NOQRTU{ɺݴ5CJOJQJ]56>*CJOJQJ CJOJQJ5CJOJQJ5CJOJQJ 5OJQJ CJOJQJ>*CJOJQJ CJOJQJ5>*CJOJQJCJ5CJOJQJOJQJOJQJ5\ CJOJQJCJCJ 2DEFGlm\F$$Ifl0x,"64 la$If ^` ABCghijkHTzz$IfF$$Ifl0x,"64 la$If3$$Ifl,""64 la*+,NO!"#$% 0^`0Q R S T U B C D E Q R   7 8 NOPQRST$a$ 0^`0TUb{  67 hRTAB` d8^`hd8`h 4hPR89:VWZ`aghijkopz{|}~0JmHnHu0J j0JU60J6OJQJj6OJQJU 6OJQJj6OJQJUOJQJ jU5CJ 0J5CJ0J5B*CJph7CJCJaJCJ5CJOJQJ5>*CJOJQJ0'FGYZ$a$$a$/ =!"#$%Dd[  c |AXO:\Kana\publications\Graphics\BigGbitmp.tifb@t:3'.'Dbn@t:3'.'PNG  IHDR >^ gAMAPLTEٟzTXtDescriptionxg̸ IDATx[EJ5#e@*v$Sg.pۋ y@0C4 O{  @ O{qPD݃6<ubzڟvu bO'DL9;u B+ ^69N+CS^)sIt4@xє8@8Q \'D,pRN#}ܭ<7 C1킔 ޳>WwMz%ޖ9‰L,{'dpeYNhr$@8Qo ֞Iy:‰zL~&p@L$Y]W}@8Qg aۨFώ /kcP\cD}(Lv>] /垉?[lI|>4ZJ @8Q$EtwpwNd7'1Absj?@1amP|\3Vou?n7u7YHXB|;,?, mEӽYG ~5L8DҩZ߲mRD FѠ8Mp"#?M[ T;(TwJ JKa~`v/q?&ǰf3VŜԃ0]@a"dB(%^m>è1nA뤟~r JXg&B֚`u!̆x Pk͇qR}RD't irnzv7,5G@I<)T݃2o< H x>'׀(֦\x,Vs9:bL8@lq!kBVV93TA0oEfkvyפL kNۘb5"ӝPLM|;xA4I{uvIl0* >w~RyM]YփRGpG~n|HN XVT |X _u`%b?sE !=I2JБfH5xםy} JVtިTTE蟐2-SedSU0jcgƀ0 jO D$ ui{G3[Ȏ5PØ8EXsi{I5 pT}d梒0Yb-m:z5q*_f[U ⺃SDi% F bԯb8Ư-]˴ %1MOHG:s10+@1gAlu7`́o+.LƁT: g1oZ> "5mu^"npI;W A,eO0qb́Q?'R2@y.XZĜZ>˪ai".eʻIa[ k#U 4A@]sZߒOYZy)\2}ͳx=֜ذFBX恞Ok 4P@P J;" 6b>Ĕx%@mgA' sDӶ-@D-]']V_'7,M ya "uDv50{]Qf!I4U? J;C,@G4eDa4 B/u`>b!c0ׂ"@(mQdf.&l1nmE Xo=qs#Xҫ bn@P߾xkl%уIed_B1 ԙZ@44 40b`!5P<0/#P <D[ VWӬnf w(}#X,X&e +ka z@uM ƫAX=+@p"o18<º+GMDV~ fB )]8kf B E7 ;D-/t NlsAةiiyhc.a\I"WO+{:H-#? tCzĎ{DnB0ʊn@5ח r[q5@ x;3!N r&AQA|P-B1{Ď @$1W%u"Ѹz?9@p= bk:sn@D Q+@pC󚟒@(0B3$V}AF@)^SR VA̗GQqlhz#U + d AD *rDь jL B`mEо #O;@gt*VVX B]?=Ԩcr6a"5ulL@p1:$U\\(ρS X Ds \A *@/C`޶. \jZ@EUdcAȤqe M ,lqɾP59[AD#Aә ikvIUNi#Dpd_ 2t>g$_B|$vZAUA %<|Jׁ<+[:eiz ~2GR3| JɾP9 ʑ}Y.M[ ,:YЙ !`zDO1eN)MJt' !`D悅;B2`r b btb,HCSg up*EL^AIB(NADDU# ND< :ӯvPEN@(/5+杧X.J:)rО ]e  tBVҏCR@(ݢT& eޱOd/!;4QzǓz@BՒs "@0B*}vS/9PwW.I@[C @廒Pnj )M ԋr2 B usAN[O&'9YO% bzumN"/۷& b;ܤ$#\wJID`@Ϛ ufufe xkZV KobK@aV b;T;_ b zgm ` ߈ bI a0NѴ9'}:m ]П1 D\ (Ư@AD r bU,@_- BIP{]u ]~ l FY @@shgP .2@|ha=u A(3:BBB \S{@Giu\!= " Dc Dl S#9Y'guhi HZ/3(sr7o+@URˑ"ԍ#3 x`wȼ̨tau J2`d0˅l 8׶},ޙIĸġ qjADܓ =0ċkIzȾDQM 5+@$3 Ę{1*S'tFI<@,bᆭQh2!'.&.! BbD0@Cm,DP 0W` "@naqm"@fbx'}I1}n/}y{ﮐN(KFsVZ׀Wf|.Jw80[CAƌ:d ɑA@ă8ZU/vC5a4 3:Do-!d3 ȬWAU Ȍ} ,%t!a ^&`] T?[@CVƽzGq\bDR ؂Nv6~4@l;8._"-/6Q,A) 8".-S 6[c_ B>" u iHA\;*Vy :! !y. xAGP1 E5+A3:`zı&rRb2>P8.?S ֝!6p9qRXft☼H{'l W H}FrR%^w R< A]Cc  !m2Pzġ{DF[`k 뎗 '.A,־P#9< ME- P}#@L܉ hDʀPj2s֌"# br㡵/e[D 2G UG&Z B`΀o-ė bBA!93pP!QSgLQ&b0Y Gs ^ɡ\@='@$>1e@FbygiA(kvS Tb9?.*F`X<"wqĖh/D bzxRM#Ȃی.^*kv"րXHzn @Y4ZA0:ec(g@,w #0,1XrbBK@Vke9ۿ͹DO0L DcQCl fPAπX"-ICTe<$+a9@Ф@Dx&,@?"]Xsb ߁Bv BO7Aai7HgtVkڢnA=! 3AL[ 6NAkFơ ݁zT6<jm} 'αbYIv b]iAly7dF'⯌HNYIW 'huP{-dF;IJ ޕZc 48@<B\vړY- ĘP3 b@D3 bB)FrZf⟥hPAj &NEa?>S5!@v7hјH8GDD%t)d8GDd`qHDDDBsND@ m J$X&$m Nt8IDDDD8T ^)@$p"i N@8@8@x)q‰‰‰F8@%p"p"p""41@O*‡‰‰‰‰‰‰‰‰‰^?\DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD"'sD m/ĩ/wTE!p"b_B#@*p@+p]k‹:<N8~d5_G8YDW8[DĎk=!vS'dmО@8Q Ɩ5z/eJ+};K]8 ^D@T;խ ܨtL‰0~{V=<4kkoGN /wiub:1N/ ^z&^@kmͅ‰zAǯ>zfNN v.ށnsN z.:tdLE݀`wP0g/[=~|'bw5:@8Q? Pog/Y "73uM2}SB'[Y*X9@8QG t<Q@8QO F}LE=3h&S WuM囹Su/@xP"Q@8Q_ DߔP g0@xlo=@xQg FI"Uy ^$A(Qw=@xQo InWo.Uqg/T.‰!QAD(߮;Uux~&u5@xQa#<_‰zvy7DD‹aOz\@8Q Ω[EIz}: p~A$K3@Q X+Gw-p"p"p\zIENDB`DyK www.evergreen.edu/employmentyK Hhttp://www.evergreen.edu/employment i0@0 Normal_HmH sH tH 88 Heading 1$@& CJOJQJ:@: Heading 2$@&5OJQJ\B@B Heading 3$@&5CJOJQJ\aJ<A@< Default Paragraph Font,@, Header  !, @, Footer  !2B2 Body Text CJOJQJ(U@!( Hyperlink>*B*HC@2H Body Text Indent ^ 5OJQJ:PB: Body Text 2 0]0OJQJVTRV Block Text00]0^0B*CJOJQJ^JaJph4>@b4 Title$a$CJ$OJQJaJ"W@q" Strong5\:J@: Subtitle$a$5CJ$OJQJ&)@& Page Number,DEFGlABCgjk*+,NO!"#$%QRSTUBCDEQR78 N O P Q R S T U b { 6 7 4pAB'FGYZ00000000000000000000000000(000000000000000000000000000000000000@0% @0% @0% @0% @0% @0% @0% @0% @0% @0% @0% 0000000000(0(00000000000000000000000000@0@0@0@0@0@0@0@0@0@0 0cc TcX!ttW`jo}O]7SWWZ`jo}33333GBCfERU b GWZ`jo}carpentl4O:\FORMS\DRAFTS\DRAFT REASONABLE ACCOMM 11-10-03.doccarpentl.O:\FORMS\REASONABLE ACCOMMODATION 11-10-03.dotcarpentlrC:\Documents and Settings\carpentl\My Documents\website\employment\resources\REASONABLE ACCOMMODATION 11-10-03.dotcarpentlrC:\Documents and Settings\carpentl\My Documents\website\employment\resources\REASONABLE ACCOMMODATION 11-10-03.dotcarpentlqC:\Documents and Settings\carpentl\My Documents\website\employment\resources\reasonable_accommodation_request.dotcarpentl-O:\FORMS\reasonable_accommodation_request.dotcarpentlEN:\Human Resource Services\Forms\reasonable_accommodation_request.dotcarpentlJN:\Human Resource Services\Forms\Reasonable Accommodation Request11-03.dotcarpentl2O:\FORMS\Reasonable Accommodation Request11-03.dotcarpentlqC:\Documents and Settings\carpentl\My Documents\website\employment\resources\reasonable_accommodation_request.dot:4+  Y S 9*6#i: j3>GY0O*6#* ^`OJQJo( hh^h`OJQJo(h^`.h^`.hL^`L.hpp^p`.h@ @ ^@ `.hL^`L.h^`.h^`.hL^`L. hh^h`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h pp^p`OJQJo(h @ @ ^@ `OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h^`.hL^`L.hpp^p`.h@ @ ^@ `.hL^`L.h^`.h^`.hL^`L.+ Yi:S 9Y0OG}HH}j3>H} S@ OJQJo(TH}87@h OJQJo(                           DFlABjM%@ (p@pp(@UnknownGz Times New Roman5Symbol3& z ArialA& Trebuchet MS?5 z Courier New;Wingdings"1h[{F[{F^yf!0d 2QDATE:The Evergreen State CollegecarpentlOh+'0 (4 P \ h tDATE:fATEThe Evergreen State Collegehe %reasonable_accommodation_request.dotft  carpentle_a2rpMicrosoft Word 9.0a@F#@RA}@Ӥ@Ӥ՜.+,D՜.+,H hp  The Evergreen State College DATE: TitleT 8@ _PID_HLINKSA  ;.$http://www.evergreen.edu/employment}m,O:\Kana\publications\Graphics\BigGbitmp.tif  !"#$%&')*+,-./0123456789:;=>?@ABCEFGHIJKNRoot Entry FXBPData  1Table(&WordDocument,SummaryInformation(<DocumentSummaryInformation8DCompObjjObjectPoolXBXB  FMicrosoft Word Document MSWordDocWord.Document.89q