Kent State University

Reasonable Accommodation Request Form

TO BE COMPLETED BY THE JOB APPLICANT

This form is used by the Office of Compliance, Equal Opportunity and Affirmative Action ("EOAA") to document an individual's request for a reasonable accommodation pursuant to the Americans with Disabilities Act, as Amended ("ADAAA") and University Policy 3342-5-16.

A job applicant requesting an accommodation for the application/interviewing process must complete this form and submit it for review and consideration. EOAA will review the request to determine if a reasonable accommodation can be provided. For example, if the application/interviewing process requires a test, the test may be given in a format or manner that does not require use of an applicant’s impaired skill, unless the test is designed to measure that skill.

EOAA may require medical documentation in order to review an accommodation request. Any medical information shared with EOAA during the application, interview, and hiring process will be kept confidential by EOAA. Only information necessary to implement a reasonable accommodation to the application/interview/hiring process will be shared with hiring personnel.

Please keep in mind that if you receive an accommodation for the application, interview, or hiring process, that does not mean you have an approved accommodation for the job, should you be the successful candidate. You will need to submit a new request for an employment accommodation to EOAA.

Applicant's Information:

Applicant’s First Name

Applicant’s Last Name

Phone

Date accommodation needed

Which position(s) are you applying for? (This information is located on the job posting.)

Job Title

Position Number

Home Organization/Department

Tell us about your impairment:

What is your impairment or disability?

What reasonable accommodations will you need during the application/interviewing process?
Check all that apply:

Assistance with completing the job application and other documents related to the hiring processAmerican Sign Language InterpreterWritten materials in accessible formats or use of assistive technologyAccessible locationProvision of equipment or deviceAssistance with written assessmentsAbility to be accompanied by an assistance animalOther

Please provide more information regarding what written materials in accessible formats or assistive technology is needed.

Please provide more information regarding what accessible location is needed.

Please provide more information regarding what equipment or device is needed.

Please provide more information for what reasonable accommodations you will need.

How will the requested accommodation(s) enable you to participate fully in all aspects of the application/interviewing process?

Please provide any additional relevant information.

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.

Applicant’s Electronic Signature

Case Origin