State of Illinois Department of Human Services

REQUEST FOR REASONABLE ACCOMMODATION

IL444-4231 (R-06-16) Request for Reasonable Accommodation Printed by Authority of the State of Illinois - 0 - Copies Page 1 of 2

Name: Payroll Title:

Work Address:Social Security Number:

Work City, and Zip Code: Division/Bureau:Phone Number (Work):

(Voice) Phone (Work) (TTY):

Home Address:Home Telephone Number:

Disability:Major life activity limitation(s):

A. Describe the specific accommodation(s) requested:

B Alternative accommodation(s):

Why is the accommodation necessary to perform your essential functions?

For Assistive care - frequency of use:

For technology - compatibility with existing equipment:

The purpose of this form is to assist DHS in determining whether or to what extent a reasonable accommodation is required for the employee/applicant to perform the essential functions of his/her job. (Please be specific and complete when filling out this form). This information is voluntary. Decisions on your request will be based on the information provided. Your answers will be kept confidential and used in compliance of applicable federal and state laws; and is regarded as Protected Health Information subject to HIPPA Policy. "Disability" includes a physical or mental impairment that substantially limits one or more major life activities, such as walking, talking, sitting, breathing, lifting, standing, working and learning. "Reasonable accommodation" includes any modification or adjustment to the job application process and the work environment that enable qualified applicants or employees to be considered for a position, to perform the essential functions of a position and to enjoy equal benefits and privileges of employment. Attach any available specific product information which is being requested to fulfill this accommodation request and a copy of present job description.

Type of accommodation requested (check one):Assistive Care Technology/Accessibility Restructuring/Modification Other

C Specific essential function(s) of your job which you are unable to perform without a reasonable accommodation:

State of Illinois Department of Human Services

REQUEST FOR REASONABLE ACCOMMODATION

IL444-4231 (R-06-16) Request for Reasonable Accommodation Printed by Authority of the State of Illinois - 0 - Copies Page 2 of 2

Name: (Print) Title

Signature

If recommended: Cost Center Number:

Appropriation Number:

Applicant/Employee (Printed Name):

In addition to narrative description, please attach (1) Job Description and (2) Physician's Medical Review Form IL444-4232 and any other medical reports or other information that will assist in reviewing your reasonable accommodation request. I certify that I have read and reviewed the job description for my position and/or been informed of the essential functions of my job. I further certify that the foregoing statements are complete, accurate and true to the best of my knowledge.

Forward to immediate (or interviewing) supervisor

REASONABLE ACCOMMODATION RESPONSEInterviewing Officer or Supervisor: Complete and forward to ADA/Reasonable Accommodation Liaison within 5 business days of receipt (if providing the accommodation mark recommended and describe the accommodation provided).

ADA Reasonable Accommodation Liaison: Complete and forward to Bureau of Accessibility and Job Accommodation, 100 South Grand Avenue East, 2nd FL, Springfield, IL 62762, phone 217/782-7691, TTY 217/557-5564, fax 217/558-1050 within 5 business days after receipt.

Comments and Recommendations:

Is Physician's medical review attached? Is job description attached?

Date:

Date Received Date Signed

Comments and Recommendations:

Yes No Yes No

Recommended Not-Recommended

Recommended Not-Recommended (Explain Why) below:

Applicant/Employee Signature:

Name: (Print) Title

Signature Date Received Date Signed