City of St. Louis Office on the Disabled

ADA Accommodation Intake Questionnaire

Date:

First Name: Middle or Initial Name: Last Name:

Address: Apt No.

City: State: Zip Code:

Telephone Number: Work: ()- - Home: ()- -

Dept/Div:

Job Title: Supervisor:

Supervisor's Title: Supervisor Phone Number: ()- -

What impairment(s) do you have that you believe should give you reasonable accommodations on the job?

Are you currently under a healthcare professional's care for this impairment? Yes No
If so, what is the doctor's name and address?
Check those activities substantially affected by your impairment(s):
walking standing sitting speaking breathing
seeing hearing manual tasks lifting caring for oneself
other (Please describe)
Explain how your impairment(s) affect the activities you checked above:

Is/are your impairment(s) temporary or permanent?
temporary permanent
If temporary, how long do you anticipate the impairment(s) will last?

What, if any, medical treatment do you receive for your impairment?
a. Does your treatment necessitate taking time off of work? yes No

b. If yes, how much time? How often do you need to take off?

c. Are you currently on a reduced schedule or leave? yes No

d. If yes, what is your current work schedule and what type of leave are you using?

List the specific job duties affected by your impairment(s):
How frequently do you perform these duties?
Explain how your impairment(s) affect these duties:
What modifications to your job duties or work environment, including the use of a device or technology, do you believe would allow you to perform the above listed duties? Explain in detail such modifications, device or technology and how this modification would allow you to perform these duties.
Do you already have any modifications to your job duties or work environment? yes No
If yes, what are the modifications?
Have you communicated to a supervisor your impairment(s) and need for an accommodation before completing this questionnaire? yes No If yes,
a. Name the supervisor(s) with whom you have communicated?

b. When did you do so?

c. Did you communicate orally or in writing?

d. What was the response and was it oral or in writing?
If, because of your impairment(s) you do not believe that you can perform the duties of your current position, with or without an accommodation, is there any other job(s) in the City government that you believe you would be able to perform? yes. No
If so, what job(s)?
Is your impairment(s) the result of a work related accident? yes. No

a. If yes, have you filed a worker's compensation claim? yes No

b. If so, is it resolved or pending? resolved pending

c. Have you been, or are you, on light duty as a result of the accident? yes No

d. If so, list the time period you were on the light duty

e. Describe the restrictions applied for your light duty.

Please sign and date the form. Typing your full name constitutes as your signature of agreeance giving full consent to the Office on the Disabled to process your request for services.


SIGNATURE OF APPLICANT	DATE

To receive a PDF copy of the completed application for your records, please provide your email address prior to submitting this form.

Your Email:

PLEASE MAIL COMPLETED FORM TO: OFFICE ON THE DISABLED, CITY HALL ROOM 30, ST. LOUIS, MO 63103

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