Attachment 6 - Reasonable Accommodation Monitoring Report


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Attachment 6 - Reasonable Accommodation Monitoring Report (pdf)


Fields on the 
Illinois AmeriCorps Disability Outreach Project

REASONABLE ACCOMMODATION MONITORING REPORT

  • Program:
  • Address:
  • State:
  • Zip:
  • Contact Name:
  • Telephone:
  • Email:
  • Date accommodation approved:
  • Date of Report:
  • Specific Accommodation:
  • Date accommodation initiated (equipment ordered, worksite modification requested, etc):
  • Date accommodation completed:
  • Training Given:
    • YES
    • NO
    • Cost of accommodation:
  • Does the accommodation enable effective job functioning?
    • How?
  • Is the member satisfied with accommodation?
  • Comments/explanation:

SIX MONTH FOLLOW-UP

  • Is the member still using the accommodation?
    • YES
    • NO
      • If no, why?
  • Is the member satisfied with the accommodation provided?
    • YES
    • NO
      • If no, why?
  • Is additional accommodation (s) needed?
    • YES
    • NO
      • If yes, what additional accommodations are recommended, why?
  • Name (Program Director)
  • Signature
  • Date

Complete and forward to the
Serve Illinois Commission
535 W. Jefferson, 3rd Floor
Springfield, IL 62702