Employee Accommodation Request Form

Employee Accommodation Request Form

This form should be used for employees with personal medical conditions and disabilities.

COVID-19 Statement:

Immunocompromised individuals are most at risk from COVID-19. Individual faculty and staff members should submit their requests for accommodations for their own medical conditions through the ADA accommodation process. For guidelines on immunocompromised and other medical conditions, please refer to the CDC guidelines.

The ADA process is limited to those with personal health conditions. Those with high-risk dependents can find guidance here:

Important Notes

Accommodations specific to COVID-19 are approved on a semester-by-semester basis, given the changing nature of the pandemic.
Age alone is not considered a disability under the ADA. In order to go through the ADA process, individuals also need to have a co-occurring mental or physical impairment that causes limitations for which they are seeking accommodations. Individuals who have developed such limitations are welcome to submit the ADA medical form for review.
Pregnancy alone is not considered a disability under the ADA, unless an individual has co-existing medical conditions (e.g., pre-eclampsia, gestational diabetes). Individuals who are pregnant, but do not have other co-existing medical conditions should reach out to the Title IX office. Their support and resources team will follow up with the individual and provide workplace adjustments when it’s appropriate and reasonable. Title IX can be reached via email at titleix@austin.utexas.edu.

By initiating the employee accommodation process, you give The University of Texas at Austin permission to explore employment related reasonable accommodations. All information obtained from medical examinations and inquiries will be job-related and consistent with business necessity and will be maintained and used in accordance with the Americans with Disabilities Act, as amended (ADA), and all applicable state and federal laws, or under the provisions of any similar and appropriate sections of succeeding ADA laws.

ADA related medical files are kept separate and apart from the location of personnel files, and access is limited to those personnel involved in the implementation of workplace accommodations. By considering this request, the University does not consider or regard the person as having a disability as defined by the ADA, or any other applicable law.

The ADA Coordinators and personnel involved in evaluating an accommodation request are not covered entities as defined in the HIPAA rules. With certain exceptions, the ADA Coordinators will not disclose the diagnostic or treatment information of its employees participating in the accommodation process. There are, however, instances when your information is shared with certain individuals such as human resource personnel, first aid and safety personnel, or University personnel investigating compliance with the ADA (including OIE, Compliance, & Legal).

Directions: Provide a response to each field below.

Employee Name

University E.I.D.

Home Mailing Address

Campus Department

Job Title

Campus Location (building and suite/office number)

Primary Phone Number

Primary Email Address

Immediate Supervisor

Describe the work you do:

Identify your physical and/or mental impairment(s) for which you are requesting an accommodation and expected duration of the impairment(s):

Explain how the impairment(s) listed above affects your ability to perform the essential function(s) of your job:

List the accommodation(s) you are requesting in order to perform your essential job functions:

Upload a copy of your job description (if available).