ADA Coordinator Intake Form - Risk

STATE OF UTAHDEPARTMENT OF (Name)OFFICE OF (Name)ADA COORDINATOR INTAKE FORMThe purpose of this form is to assist the employer in determining whether, or to whatextent, a workplace accommodation is appropriate to enable an employee to performthe essential functions of his/her job.This form should be completed when an employee has requested a workplaceaccommodation. This form, and all other ADA-related information, should bemaintained in a confidential file separate from the employee’s personnel file.Date:____________________Employee Name: ________________________________Job Title: _______________________________________Initiation of ADA process (date, time, circumstances, persons involved):__________________________________________________________________________________________________________________________________________________________________________________________________________________Accommodation(s) Requested: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Mental/Physical Impairment(s) (include date of onset): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Major Life Activities Impacted: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ADA Coordinator Intake Form Page 1 of 2

Functional limitations (nature, frequency, severity, duration) of each impairment onMajor life activities (Quantify where possible. ie: how far, how long, how much. seediagnosis impairment questions if needed): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Attach Evaluation Grid if appropriate: Y___ N___Essential Functions of the Job (attach job description and performance appraisals):______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Marginal Functions of the Job: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Potential Solutions:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Ergonomic Evaluation Requested: Y___ N___ Date: _________ Who: ____________Interim Modifications if any:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Name: ______________________________________ Title: ____________________ADA Coordinator Intake Form Page 2 of 2