ࡱ > I L H bjbj 3> x x = : : } } } } } 8 $ \ \ \ i k k k k k k & k } 3 \ \ 3 3 k } } 3 R } } i 3 i ˖V7o R U 0 ^ } \ L 6 ,
) \ \ \ k k 5 | \ \ \ 3 3 3 3 \ \ \ \ \ \ \ \ \ : C : UNIVERSITY OF ARKANSAS AT LITTLE ROCK
Accommodation Request Form
Americans with Disabilities Act (ADA)
(To request accommodations, such as assistive equipment, facility modifications, flexible schedule.)
Date of Request:Name of Employee Requesting Accommodation:Address:Phone:City State ZipDaytime PhonePosition TitleDepartmentAccommodation Requested: On a separate sheet of paper please record a description of the job duties, barrier, facility or program requiring accommodation. Describe how it limits your ability to participate in a program or to perform employment tasks. Attach to this form.For University Department Use Only:Concurrence with the accommodation(s) requested by the employee Departments suggestions for accommodations, please explain:Final Resolution of the employees request for accommodations by the employee and the University
I accept the accommodations(s) identified above and offered to me by the university and agree that they are accommodations that I feel will assist me in performing the essential functions of my job.
Signatures
EmployeeUniversity Department Head
NOTE TO UNIVERSITY MANAGER AND SUPERVISORS:
To ensure that all requests for reasonable accommodations are given full consideration, managers may not deny an accommodation without further review by university officials charged with ensuring compliance with the Americans with Disabilities Act. If you feel you cannot meet the accommodation, believe that the accommodation request is unreasonable or presents an undue hardship for the university, need additional assistance in evaluating the accommodation or need resources not available in your department to provide the accommodation for classified staff, or faculty please contact the Department of Human Resources.
A Note on Confidentiality: Disability-related documents must be kept confidential. Departments or individuals should not keep any copies of such documentation within department or offices. Any existing information related to disability, including medical reports, should be forwarded in an envelope marked Confidential to the Department of Human Resources.
ADA Accommodation Form
06.01.2011
% & @ A K L g h ( G H L M R W r s w x
żϰ椔} h hs B*CJ ph h B*CJ ph h% B*CJ ph
hs CJ
hs CJ
hs CJ h% 5B*CJ ph h% h CJ h B*CJ ph
hs CJ
hs CJ h% hp
e hp
e hs hs 5h% hs 5h% h 5 / & A g h H kd $$If l 0 bj z 4
l a $If $a$ $a$gd k E kd $$If l 0 * h 4
l a $If H kdr $$If l 0 bj z 4
l a & ' ( ) G k kd $$If l \ 6$* J 4
l a $If E kdC $$If l 0 * h 4
l a ) 8 9 G H I J K L | p
" $If p kdI $$If l K \ 6$* J 4
l a ytjm $If
< " $If L M N O P Q R
" $If $If k kd $$If l \ 6$* J 4
l a R S T U V z z z $If ~ kdi $$If l r N r* J $ r 4
l a V W f g r s t B < $If X kd $$If l F * *
4
l a $$If a$[ kd
$$If l F *
*
4
l a t u v w x k kd $$If l \ N * J p F P 4
l a $If
" $If b E kd $$If l 0 * ` 4
l a $$If a$ $If H kd $$If l 0 * N 4
l a
^ 2 kd $$If l * P+ 4
l a 2 kd $$If l * P+ 4
l a $If 5 kdg $$If l * >+ 4
l a
` W $If gd 2 kd $$If l * P+ 4
l a 2 kd $$If l * P+ 4
l a $If 2 kdB $$If l * P+ 4
l a
E F G H K \ . { | } ~
Րzh? hJ) CJ aJ h? hs CJ aJ h? hs 5CJ aJ hs 5hJ) hs CJ hJ) hs 5hJ) hJ) 5 hJ) h hJ) hs h% hs
hs CJ
hs CJ hs h hs B*ph h B*ph h% h`; h% h 0 C D m E kd $$If l 0 * < ( 4
l a $If E kd+ $$If l 0 * < ( 4
l a D E F G H I k 8 2 kd $$If l * P+ 4
l a 2 kd $$If l * P+ 4
l a ( $If X kd $$If l F l* < x 4
l a I J K w o ( $If E kdq
$$If l 0 ^* 4
l a $If gd`; 2 kd(
$$If l * P+ 4
l a $If } ~ $If $a$ 2 kd' $$If l * P+ 4
l a ( $If 2 kd
$$If l * P+ 4
l a > < X kd $$If l F d* v 4
l a $If $$If a$ X kd~ $$If l F d* v 4
l a R S $
!0*a$gdfB
!% $a$gd58 $a$ , - P Q R S l ʾ휐~~~~zvlhzvz]vzvz hfB hfB CJ aJ h w h w CJ OJ QJ h3 hfB h(u j h(u U
hs CJ h*6 5B*CJ ph he CJ aJ h? hs 56CJ aJ h? hs 6CJ aJ h? hs 5CJ aJ h58 5CJ aJ
h58 CJ h58 5B*CJ ph h58 CJ aJ h{< CJ aJ h? hs CJ aJ $ $a$
hs CJ h(u h3 1 0:pfB / =!"#$% p $$If !v h5 5#v #v:V l z 5 5/ 4 b $$If !v h5 5#v #v:V l z 5 54 k $$If !v h5 h5#v h#v:V l 5 h5/ 4 ] $$If !v h5 h5#v h#v:V l 5 h54 $$If !v h5 J5 55#v J#v #v#v:V l 5 J5 55/ / 4 $$If !v h5 J5 55#v J#v #v#v:V l K 5 J5 554 ytjm $$If !v h5 J5 55#v J#v #v#v:V l 5 J5 554 $$If !v h5 J555$ 5r#v J#v#v#v$ #vr:V l 5 J555$ 5r4 $$If !v h5
5*5
#v
#v*#v
:V l 5
5*5
/ / 4 s $$If !v h5 5*5
#v #v*#v
:V l 5 5*5
4 $$If !v h5 J5p5F5P#v J#vp#vF#vP:V l 5 J5p5F5P4 k $$If !v h5 N 5 #v N #v :V l 5 N 5 / 4 ] $$If !v h5 ` 5 #v ` #v :V l 5 ` 5 4 G $$If !v h5 >+#v >+:V l 5 >+4 G $$If !v h5 P+#v P+:V l 5 P+4 G $$If !v h5 P+#v P+:V l 5 P+4 U $$If !v h5 P+#v P+:V l 5 P+/ 4 G $$If !v h5 P+#v P+:V l 5 P+4 G $$If !v h5 P+#v P+:V l 5 P+4 k $$If !v h5 <5(#v <#v(:V l 5 <5(/ 4 ] $$If !v h5 <5(#v <#v(:V l 5 <5(4 $$If !v h5 <55x#v <#v#vx:V l 5 <55x/ / 4 G $$If !v h5 P+#v P+:V l 5 P+4 U $$If !v h5 P+#v P+:V l 5 P+/ 4 G $$If !v h5 P+#v P+:V l 5 P+4 k $$If !v h5 5#v #v:V l 5 5/ 4 G $$If !v h5 P+#v P+:V l 5 P+4 U $$If !v h5 P+#v P+:V l 5 P+/ 4 $$If !v h5 5v5#v #vv#v:V l 5 5v5/ / 4 s $$If !v h5 5v5#v #vv#v:V l 5 5v54 f 2 0 @ P ` p 2 ( 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 8 X V ~ OJ QJ _HmH nH sH tH < ` < N o r m a l CJ _HmH sH tH D A D D e f a u l t P a r a g r a p h F o n t V i@ V T a b l e N o r m a l :V 4 4
l a ( k ( N o L i s t 4 @ 4 H e a d e r
! 4 @ 4 F o o t e r
! H H T\ B a l l o o n T e x t CJ OJ QJ ^J aJ PK ! [Content_Types].xmlj0Eжr(Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi} ;~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭? PK ! ֧ 6 _rels/.relsj0 }Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_ 6LR7`0̞O,En7Lib/Se е PK ! ky theme/theme/themeManager.xml M
@}w7c(Ebˮ CAǠҟ7՛K
Y,
e.|,H ,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8 PK ! P theme/theme/theme1.xmlYOo6w toc'vuر-Mn iP@I}úama[إ4:l ЯGRX^6؊>$ !)O^rC$y@ /yH*)UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSe bORD۫qu gZo~ٺlAplxpT0+[}`j zA V2Fi@qv֬5\|ʜ̭NleXd sjcs7f
W+Ն7` g ȘJj|h(KD-
dXiJ؇(x$( :;˹! I_TS 1?E ??ZBΪmU/ ?~xY'y5g&/ɋ>GMGeD3Vq%'#q$8K )fw 9:ĵ
x}rxwr:\TZaG*y8IjbRc|XŻǿI
u3KGnD 1NIBs
RuK>V.E L+M2#'fi ~V vl{u8z H
* :( W ☕
~JTe\O*tHGHY }KNP*ݾ˦ TѼ9/#A7qZ $*c?qUnwN%Oi4 =3ڗP
1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g-
eW
)6-rC Sj
id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q% p%m&]caS l=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f
Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ .uχYC6OMf3or$5N HT[XF64T,ќM0E)`#5XY`פ ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R 3U~7+#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vp IYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07% < ҍ PK !
ѐ ' theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э5
6?$Q
,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/ ]QAsم(#L[ PK- ! [Content_Types].xmlPK- ! ֧ 6 + _rels/.relsPK- ! ky theme/theme/themeManager.xmlPK- ! P theme/theme/theme1.xmlPK- !
ѐ ' theme/theme/_rels/themeManager.xml.relsPK ]
> 8 : < ?
) L R V t
D I
8 @ 0 (
B
S ? ۫ ̳{ ۫ ۫ ,x ۫ ۫ b b
e e 9 *urn:schemas-microsoft-com:office:smarttagsplace 8 *urn:schemas-microsoft-com:office:smarttagsCity = *urn:schemas-microsoft-com:office:smarttags PlaceType = *urn:schemas-microsoft-com:office:smarttags PlaceName - 0 h 3 , S , S # " At ' g " J) *6 58 : `; {< o1? T\F p
e jm w s 3 TZ u~ w T\ [Q % r` fB ? PL - _ e (u @ h @ U n k n o w n G * T i m e s N e w R o m a n 5 S y m b o l 3. * A r i a l [ B o o k m a n B o o k m a n O l d S t y l e 3 * T i m e s 5. * a T a h o m a A B C a m b r i a M a t h " h tG
M p M p ! 24 d [ 3q HX ? : 2 ! x x 3 V i r g i n i a P o l y t e c h n i c I n s t i t u t e a n d S t a t e U n i v e r s i t y
V i r g i n i a T e c h l w d a v i s Oh +'0 ( 4
T ` l
x 4 Virginia Polytechnic Institute and State University Virginia Tech Normal.dotm lwdavis 3 Microsoft Office Word @ G @ 6RH!@ h!@ H67o M p ՜. +,0 $ h p
VPI & SU 4 Virginia Polytechnic Institute and State University Title
! " # $ % & ' ) * + , - . / 0 1 2 3 4 5 6 7 9 : ; < = > ? A B C D E F G J K N R o o t E n t r y F ІV7oM D a t a
1 T a b l e ( W o r d D o c u m e n t
3> S u m m a r y I n f o r m a t i o n ( 8 D o c u m e n t S u m m a r y I n f o r m a t i o n 8 @ M s o D a t a S t o r e ZV7o˖V7o A G X B R E G K X A I U = = 2 ZV7o˖V7o I t e m
P r o p e r t i e s U C o m p O b j
y
F' Microsoft Office Word 97-2003 Document
MSWordDoc Word.Document.8 9q