Americans with Disabilities Act of 1990 (ADA) Request Form

Americans with Disabilities Act of 1990 (ADA) Request Form
Orion Associates, Meridian Services, and Zenith Services are committed to complying with the Americans with Disabilities Act (“ADA”) and the Minnesota Human Rights Act (MHRA). To be eligible for an ADA accommodation, you must be qualified to perform the essential functions of your position and have a qualifying disability. A person is defined as having a disability under the ADA if they are (1) a person who has a physical or mental impairment that substantially limits one or more major life activities, (2) a person with a record of a physical or mental impairment that substantially limits one or more major life activities, and (3) a person who is regarded as having a physical or mental impairment that substantially limits one or more major life activities.

Fill out this form to request an accommodation(s). You must submit a doctor’s note to support the accommodation request. The doctor’s note must describe the nature, severity, and duration of the impairment, the activity or activities that the impairment limits, the extent to which the impairment limits your ability to perform the activity or activities. The submission will route to Human Resources for review.

For questions, please contact Andrea Hagen at ahagen@orionassoc.net or 763-450-5008.
Company*
Employee Legal Name *

Legal First NameLegal Last Name
Employee Email*
example@example.com
Employee Phone Number*
Please enter a valid phone number.
Location*
Program or Department*
Position*

Important Notices
Data Privacy Statement: This information may be used by your ADA Coordinator or designee, legal counsel, or any other individual who is authorized by Meridian Services to receive medical information for purposes of providing reasonable accommodations under the ADA and MHRA. This information is necessary to determine whether you have a disability as defined by the ADA or MHRA, and to determine whether any reasonable accommodation can be made. The provision of this information is strictly voluntary; however, if you refuse to provide it, your agency may refuse to provide a reasonable accommodation.
Information Pertaining to Medical Documentation: In the context of assessing an accommodation request, medical documentation may be needed to determine if the employee has a disability covered by the ADA and to assist in identifying an effective accommodation. The ADA Coordinator or designee is tasked with collecting necessary medical documentation. In the event that medical documentation is needed, the employee will be provided with the appropriate forms to submit to their medical provider. The employee has the responsibility to ensure that the medical provider follows through on requests for medical information

A. Questions to clarify accommodation requested
1. What specific accommodation are you requesting?*
2. If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore?

YesNo
If "yes" please explain
B. Questions to document the reason for the accommodation request (please attach additional pages if necessary)
1. What, if any, job function are you having difficulty performing?*
2. What, if any, employment benefits are you having difficulty accessing?
3. What limitation, as a result of your physical or mental impairment, is interfering with your ability to perform your job or access an employment benefit?*
4. If you are requesting a specific accommodation, how will that accommodation be effective in allowing you to perform the functions of your job?*
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ADA Employment Rights

This notice can be found at https://www.eeoc.gov/laws/guidance/your-employment-rights-individual-disability
The ADA: Your Employment Rights as an Individual With a Disability

Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
This authorization does not cover, and the information to be disclosed should not contain, genetic information. “Genetic Information" includes: an individual’s genetic tests; information about genetic tests of an individual’s family members; information about the manifestation of a disease or disorder in an individual’s family members (family medical history); an individual’s request for, or reciept of, genetic services, or the participation in clinical research that includes genetic services or the participation in clinical research that includes genetic services by the individual or a family member of the individual; and genetic information of a fetus carried by an individual or by a pregnant woman who is a family member of the individual and the genetic information of any embryo legally held by the individual or family member using an assisted reproductive technology.
Employee Legal Name *

Legal First NameLegal Last Name
Employee Signature*

Clear
Date of Signature*

MonthDayYear
Date
Please verify that you are human*
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Americans with Disabilities Act of 1990 (ADA) Request Form

Important Notices

A. Questions to clarify accommodation requested

B. Questions to document the reason for the accommodation request (please attach additional pages if necessary)

ADA Employment Rights

Signatures