TEANECK BOARD OF EDUCATION HUMAN RESOURCE MANAGEMENT

ADA ACCOMMODATION REQUEST FORM

Please complete the appropriate section of this checklist. This form should be returned to Human Resource Management via email at: covidhealthdocs@teaneckschools.org. PLEASE NOTE ALL ACCOMODATION REQUESTS REQUIRE MEDICAL CERTIFICATION.

Employee Name	________________________	School/Dept.	______________________________

Contact Information: Email ____________________

Phone ____________________

ADA Accommodation Requests pertain to disabilities that include a physical or mental impairment that substantially limits one or more major life activities. On June 25, 2020 the Center for Disease Controls revised its guidance to include conditions that may place people at an increased risk for severe illness from COVID-19.

____ I am seeking accommodations under the ADA because I am at high risk for contracting the COVID-19 virus under the CDC’s pandemic guidelines. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-increased-risk.html

____ I am seeking accommodations under the ADA for non-COVID-19 related reasons.

https://adata.org/factsheet/reasonable-accommodations-workplace

1. What if any, job function are you having difficulty performing?

2. How does your disability affect the essential functions of your job?

______________________________________________________________________________

3. Do you have a suggestion on an accommodation?     Yes	No

If yes, please describe how it will assist you:

______________________________________________________________________________

4. I am seeking an accommodation for the period ___________ to _____________.

I have attached a completed Physician’s Certification form.

The Physician’s Certification is being sent under separate cover.

I have not yet seen my physician. My appointment is ____________________________.

I certify that the above information is true and correct to the best of my knowledge:

Employee Signature________________________________________ Date: ______________

Determination of eligibility, and/or additional documentation or clarification of documentation, may be required prior to making a final determination.

Documentation Received

Accommodation Approved

For Employer Use Only

____________________

Date

(See separate Approval Form) ________________________

Date

Accommodation Denied (See separate Denial Form ) ______________________________

Date

Accommodation Approved for the Period ____________________________________________

Dates

Return to Work Criteria

The New Jersey Restart and Recovery Plan for Education, “The Road Back” states that in all stages and phases of pandemic response and recovery, schools must comply with Center for Disease Control (CD), state and local guidelines for health and safety. Please consult the following link for the NJDOH/CDC guidelines for returning to work.

https://www.nj.gov/health/cd/documents/topics/NCOV/COVID-QuickRef_Discont_Isolation_and_TBP.pdf