Kent State University

Reasonable Accommodation Request Form

TO BE COMPLETED BY THE EMPLOYEE/STUDENT

This form is used by the Office of Compliance, Equal Opportunity and Affirmative Action (“EOAA”) and the Office of Gender Equity and Title IX (“Title IX”) to document an individual’s request for a reasonable accommodation pursuant to the Americans with Disabilities Act, as Amended (“ADAAA”), The Pregnancy Discrimination Act (“PDA”), Title IX of the Education Amendments of 1972, and University Policy 3342-5-16.

A university employee or pregnant/parenting student requesting an accommodation must complete this form and submit it for review and consideration.

Employee Accommodations:

EOAA and Title IX will also consult with department leadership and the employee’s direct supervisor and may require additional medical documentation consistent with university policies and procedures when reviewing a workplace accommodation request. All information will be maintained in accordance with applicable confidentiality requirements.

Student Accommodations:

Title IX will consult with the student’s professor(s) and may require additional medical documentation consistent with university policies and procedures when reviewing a pregnancy accommodation request. All information will be maintained in accordance with applicable confidentiality requirements.

Student Accommodations for a chronic medical condition or medical disability as a result of a pregnancy should be requested via Student Accessibility Services (SAS) [https://olympic.accessiblelearning.com/Kent/ApplicationStudent.aspx]

Information:

First Name

Last Name

Banner ID

Job Title/Student Classification

Department/Campus

Division/College

Phone

Please select if you are an employee or a student.

Is this a pregnancy related accommodation?

Mailing Address

Supervisor’s information:

Name

Title

Phone

Tell us about your disability or impairment:

If this request is time sensitive (i.e., there is a specific date or event for which the accommodation is needed), please indicate the date by which an accommodation is needed.

What is your impairment or disability?

Tell us about your pregnancy:

Student - Is this a chronic medical condition or medical disability as a result of a pregnancy?

Please describe the reasonable accommodation you are requesting:

Please indicate the date by which an accommodation is needed.

How does your pregnancy affect your ability to access benefits and/or successfully complete the position’s essential job functions as defined in your job description?

How does your impairment or disability affect your ability to access benefits and/or successfully complete the position’s essential job functions as defined in your job description?

Why are you requesting a reasonable accommodation at this time (i.e. position change, change in ability)?

What specific accommodation(s) are you requesting?

How will the accommodation(s) listed above assist you in accessing the benefits and/or performing the position’s essential job functions?

Is this is a chronic medical condition or medical disability as a result of a pregnancy, this may qualify as an ADA workplace accommodation?

Please provide any additional relevant information.

Student Accommodations for a chronic medical condition or medical disability as a result of a pregnancy should be requested via Student Accessibility Services (SAS) Please click the following link to submit this request.

https://olympic.accessiblelearning.com/Kent/ApplicationStudent.aspx

Case Origin

If you would like further information or need assistance submitting this request please contact Student Accessibility Services (SAS) at 330-672-3391 or email sas@kent.edu.

You may be asked to further clarify the information that you have provided on this form. Without complete documentation, EOAA may not be able to adequately respond to this request.

I affirm the information provided in this form is true and accurate to the best of my knowledge.

You may be asked to further clarify the information that you have provided on this form. Without complete documentation, the Office of Gender Equity & Title IX may not be able to adequately respond to this request.

Signature