Attachment 5 - Reasonable Accommodations Request Form


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Attachment 5 - Reasonable Accommodations Request Form (pdf)


AmeriCorps Illinois

Text Version of: 
Illinois AmeriCorps Disability Outreach Projects 
Request for Reasonable Accommodation

The purpose of this form is to assist the Serve Illinois Commission (SIC) in determining whether or to what extent a reasonable accommodation is required for an AmeriCorps member to perform essential functions of his/her position. (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.

"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 members to be considered for a position, to perform the essential functions of the 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.


  • Name:
  • Soc. Sec. No.:
  • Program Name:
    • Host Site:
  • Program Address:
    • Phone:
  • Home Address:
    • Phone:
  • Disability:
  • Major Life activity limitation (s):
  • Type of accommodation requested (check one):
    • Assistive Care
    • Restructuring/modification
    • Technology/accessibility
    • Other
  • A. Describe the specific accommodation (s) requested:
  • B. Alternative accommodation (s):
  • C. Specific essential function(s) of your job which you are unable to perform without a reasonable accommodation:
  • Why is this accommodation necessary to perform your essential functions?
  • For assistive care - frequency of use:
  • For technology- compatibility with existing equipment:

In addition to narrative description, please attach (1) Job Description and (2) Physician's Medical Review Form 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 position description for my service and/or been informed of the essential functions of my position. I further certify that the foregoing statements are complete, accurate and true to the best of my knowledge.

  • Applicant / Member Signature
  • Date

Forward to immediate (or interviewing) supervisor.


REASONABLE ACCOMMODATION RESPONSE

Interviewing Officer or Supervisor: Complete and forward to the Serve Illinois Program Officer within five (5) business days of receipt.

  • Name (print)
  • Title
  • Signature
  • Date Received
  • Date Signed
  • Recommendations:
    • Recommended for reasonable accommodation with program/host fulfilling the accommodation request, no SIC requested
    • Recommended for reasonable accommodation with assistance provided by SIC to fulfill the accommodation.
    • Requested amount from SIC to fulfill accommodation:
    • Not recommended for reasonable accommodation
    • Comments:
  • * Is Physician's medical review attached? Yes No
  • * Is job description attached? Yes No

Complete and forward to the

Serve Illinois Commission
535 W. Jefferson, 3rd Floor
Springfield, IL 62702

or you may fax the form to 217-557-0515.

SIC will:

  • Approval granted for requested reasonable accommodation
    • Approved amount, designated for request:
  • Deny requested reasonable accommodation
    • Explanation:
  • Comments:
  • Name (print)
  • Title
  • Signature
  • Date Received
  • Date Signed