Request for Reasonable Accommodation

First and Last Name *

Employee ID Number *

Phone Number *

Position *

Location *

Principal/Supervisor *

Nature of the Qualifying Event *

Requested/Suggested Accommodation (Please describe the accommodations you believe are needed to enable you to perform the essential functions of this job.) *

Physician Contact Information (Please provide name, address, telephone, and fax numbers.) The physician may receive a letter/fax from us requesting information on your impairment/disability and recommendations for accommodations. *

I authorize the release of necessary confidential medical information regarding my disability to relevant members of the District as deemed necessary by Human Resources.

Signature * 🛈

clear

Date * +

[To signatory: In non-physician review cases, decisions regarding accommodations will be made within 10 days of the receipt of this form by Human Resources. Due to delays that may be caused in communications with physicians, no specific decision date can be provided for physician review cases.]

NON-DISCRIMINATION STATEMENT:

The Sioux City Community School District offers career and technical programs in the following areas: Business & Marketing, Family & Consumer Science, Health Science, and Industrial Arts, Technology, & PLTW.

The Sioux City Community School District is an equal opportunity/affirmative action employer and does not discriminate on the basis of race, creed, color, sex, sexual orientation, gender identity, genetic information (for employment), national origin, religion, age (for employment), disability, socioeconomic status (for programs), marital status (for programs), or veteran status (for employment) in its educational programs and its employment practices. The District is required by Title IX and 34 CFR Part 106 not to discriminate on the basis of sex in its programs, activities, or employment.

Inquiries or grievances under Section 504 and Title II of the Americans with Disabilities Act may be directed to Dr. Dora Jung, Director of Student Services & Equity Education/Title IX Coordinator at 627 4th Street, Sioux City, IA 51101, (712) 279-6075, jungd@live.siouxcityschools.com. Inquiries about the application of Title IX and its regulations to the District may be referred to the Title IX Coordinator, the Assistant Secretary of the U.S. Department of Education, or both. Please see District Board policies 103 and 504.4 for additional information on available grievance procedures.