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Disability Services

Request for Services Webform-Employees

Central Washington University
Employee Notification of Disability and Request for Accommodation(s)
CONFIDENTIAL

*This form is to be used in conjunction with CWU Policy 2-2.2.1.5 and CWU Procedure
2-2.2.1.6*

I.  TO BE COMPLETED BY EMPLOYEE

Notification  I hereby notify Central Washington University as my employer that I believe I am a person with a qualifying disability under Federal and/or State law, the definitions of which are available below.

Note: If you would rather fill out a traditional paper form, please feel free to fill out our Request for Services Form (pdf). You may then email it as an attachment, fax it, or mail it to us. Our contact information can be found on our Home Page.

Enter your CWU Email address

Request for Accommodation(s)
I hereby request the following accommodation(s) which I believe will negate the effect(s) of the functional limitation(s) of my disability/disabilities and allow me to perform the essential functions of my position.  I understand that I am responsible for providing documentation of my disability from an appropriate health care professional that supports this request for accommodation(s).  I understand my request for accommodation(s) will be discussed in a collaborative manner with my supervisor and, if necessary, other appropriate CWU personnel.  I understand that if, in the future, the nature of my disability or my work assignment changes, I have the right to request other accommodation(s).

Please identify the accommodations you are requesting.

Documentation

Documentation to be sent to:   Human Resources/Disability Services
                                                 Central Washington University
                                                 400 E. University Way
                                                 Ellensburg,  WA  98926-7425
Link to Medical Release Webform (This form is to be filled out after you have successfully submitted your Request for Services)

I understand CWU's HR/DS will share appropriate information from the health care provider statement with my supervisor regarding the functional limitations of my disability and any recommended accommodation(s).

Enter the name and credentials of your Medical Provider
Enter the telephone number of your Medical Provider
By submitting this form, I verify the accuracy of the information provided, and confirm my intention of entering into the accommodation process.

Definitions

Equal Employment Opportunity: The term equal employment opportunity means an opportunity for a qualified individual with a disability to perform the essential job functions or to enjoy equal benefits and privileges of employment as are available to a similarly-situated applicant or employee without a disability.

Essential Functions: The term essential functions means the fundamental job duties of the position that the individual with the disability holds or has applied for.  The term essential functions does not include the marginal functions of the position

Person with a Disability: The term person with a disability means:
1.  Under 42 U.S.C. 12102, a person with a physical or mental impairment that substantially limits one or more major life activities (e.g., walking, speaking, breathing, seeing, hearing, working, etc.); or

2.  Under chapters 49.60 RCW and 162-22 WAC, a person who has an abnormal condition that is medically cognizable or diagnosable, and who is denied reasonable accommodation(s) or is discriminated against on the basis of that condition.

Reasonable Accommodation(s): The term reasonable accommodation(s) means modification or adjustment to a job, work environment, policy, practice, or procedure that enables a qualified  individual with a disability to enjoy equal employment opportunity and does not impose an undue hardship on the employer.  This includes, but is not limited to: adaptive technology; special furniture or equipment; changes in work schedules, percent of full time, or job structure; physical changes or office relocation to make facilities accessible and usable; assignment to a different available position of at least fifty percent time; opportunity to apply for other employment for which the individual qualifies (including promotion, transfer, lateral movement and demotion opportunities) within the institution; and/or leave of absence.

Health Care Professional: The term health care professional means a person who has completed a course of study and is licensed to practice in a field of health care which includes the diagnoses and assessment of the particular disability or disabilities in question.

Qualified Individual with a Disability: The term qualified individual with a disability means an individual who meets the skill, experience, education, and other job-related requirements of the position held or applied for, and who, with or without reasonable accommodation(s), can perform the essential functions of the job.

Undue hardship: The term undue hardship means an excessively costly, extensive, substantial, or disruptive modification, or one that would fundamentally alter the nature or operation of the institution or program.