Form Center • ADA Reasonable Accommodation Request

Introduction

Introduction
This form is to be used by City employees and job applicants seeking a reasonable accommodation relating to their employment or application for employment pursuant to the Americans with Disabilities Act (Title I) and/or Section 504 of the Rehabilitation Act of 1973. The City is committed to equal opportunity in all aspects of employment for qualified disabled individuals. Information regarding the City’s ADA policy is also available on the City's website.
If you have questions or need assistance completing this form, please contact:
Randolph Wilkerson
ADA Co-Coordinator and Human Resources Director
City of Murfreesboro
111 West Vine Street
Murfreesboro, TN 37130
Telephone: (615) 848-2553
Fax: (615) 904-6506
Email: rwilkerson@murfreesborotn.gov
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Section A: Individual Requesting Reasonable Accommodation
First Name*
Last Name*
Address1*
Address2
City*
State*
Zip*
Day Time Telephone*
Cell Phone
Email*
Work Phone
Are you a current City employee or a job applicant?
1. Current Employee
2. Job Applicant
Position held or sought*
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Section B: Reasons for Requesting a Reasonable Accommodation
Please identify and describe your health condition or mental or physical limitation that constitutes your disability. *
(Note: The City may require additional information to evaluate this request and may ask that you submit a statement or other medical documentation from your healthcare provider.)
Please describe briefly how your disability interferes or may interfere with your ability to: (a) perform the essential functions of your current or desired job; (b) access one or more employee benefits; or (c) participate fully in the job application process. *
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Section C: Accomodation Request
If you are requesting a specific accommodation(s), please describe the accommodation(s) you are requesting and how you believe it will assist you.
(If the accommodation is a device or other item that can be purchased, please identify the item’s manufacturer, model number, and price and how the item can be purchased.)
If you are not sure what accommodation(s) you need, please suggest any possibilities that you believe the City should consider.
If the disability, health condition, or limitation has been accommodated in the past, please indicate the accommodation(s) and its/their effectiveness.
Please provide any additional information that will help the City evaluate your request:
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Section D: Certification of Disability and Need for Reasonable Accommodation
I certify that I have a disability that requires reasonable accommodation and that the information I have provided on this form is accurate and complete to the best of my knowledge.
By entering my name here I agree to the above statement.*
Date*
Date

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