Office of Equal Opportunity & Affirmative Action

University Visitors & ARUP Employees Request for Disability Accommodation Form

Consistent with the Americans with Disabilities Act (ADA), the University of Utah provides reasonable accommodations to qualified individuals with disabilities. The University's Office of Equal Opportunity and Affirmative Action (OEO/AA) is charged with determining reasonable accommodations under the ADA and facilitating the provision of those accommodations for ARUP employees and visitors to the University campus.

A downloadable version of the form is available.

After you complete your submission, you will receive a response and updates from the OEO/AA as your request is processed by the assigned staff member. If you have questions or concerns, please contact oeo@utah.edu or 801-581-8365.

Status

uNID (if Applicable)

First Name

Last Name

Preferred Name

Pronouns

Preferred Phone Number

Preferred Email Address

This will be the primary form of communication unless otherwise indicated

Home Address

Supervisor's Name

Supervisor's Email

Job Title

Please answer the following questions to assist us in understanding the basis and nature of your request for a reasonable accommodation.

Describe the nature of your Disability:

(e.g. visual limitation, arthritis, etc.)

Explain how your disability limits one or more essential functions of your job or your ability to visit the University of Utah campus:

Describe the reasonable accommodation that you are requesting. Be Specific. For accommodation ideas visit www.askjan.org :

Has a physician or other health professional recommended a specific accommodation? If yes, please attach relevant documents.

YesNo

Please attach a copy of their recommendations

Medical Information Release

I voluntarily give the University of Utah’s Office of Equal Opportunity and Affirmative Action permission to contact my physician(s) and/or health care provider(s) as listed below for the purpose of evaluating my request for accommodation.

Medical Provider Information

Name of Physician/Health Care Provider

Name of Hospital/Practice

Physician/Health Care Provider Address

Physician/Health Care Provider Phone Number

I understand that the University of Utah’s Office of Equal Opportunity and Affirmative Action cannot properly evaluate my request for accommodation unless I approve this release and that any information disclosed under this release could potentially be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations. I further understand that relevant information obtained may be shared with the supervisor(s) in my immediate work unit and other University offices that may be involved in assisting in the development of reasonable accommodations to assist me in completing my assigned work-related responsibilities.

I understand that I can revoke this release in writing at any time by sending a written revocation of authorization to the University of Utah’s Office of Equal Opportunity and Affirmative Action. However, I understand that my revocation will not be effective to the extent that action has been taken under the release.

By submitting this release, I represent that I have read the information, understand it, and agree with the authorization I now make.