New Form

ADA Accommodation Request

Enter the following information. Fields with an asterisk (*) are required.

If, after addressing your request, you believe that your rights under the ADA have not been enforced, you may file a complaint with the Arlington County Office of Human Rights, EEO and ADA. For ADA accommodations, questions regarding the ADA, or assistance using the online form system please contact Anthonia Sowho at (703) 228-3559 or asowho@arlingtonva.us.

NOTICE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information.

“Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or family member’s sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Your Information

Name *

I am a / an *

current Arlington County Government employee applicant for employment with Arlington County Government

Job Title *

Email Address *

Work Phone *

Home / Cell Phone *

Medical Provider Phone

Worksite / Location *

Supervisor *

Supervisor Email Address *

Department *

Department_Abbrev

Department Head Email Address *

Medical Provider Name

If applicable.

Medical Provider Email Address

If applicable.

ADA Accommodation Request

Information about your Accommodation

Enter the following information about the accommodation you are requesting. Fields with an asterisk (*) are required.

What specific accommodation are you requesting? *

How will this accommodation assist you? *

I'm not sure what specific accommodation I need

Suggest any other alternative accommodations (optional).

ADA Accommodation Request

Information about your Accommodation

Enter the following information about the impact this accommodation would have on your employment. Fields with an asterisk (*) are required.

What, if any, job function are you having difficulty performing? *

Have you had any difficulty accessing any Arlington County employment benefit? *

e.g. Wellness programs, training, etc.

Have you had any accommodations in the past for this same limitation? *

Yes No

What were they and how effective were they? *

Please provide any additional information that might be useful in processing your accommodation request. *

ADA Accommodation Request

Upload Documentation

Use this page to upload any files relevant to your request for accommodation, such as notes from your doctor, photos of your workspace, and/or work document samples.

Click 'Add File' to add as needed.

Upload File

Upload

File Description

ADA Accommodation Request

Acknowledgements and Submission

I release my medical provider(s) cited in this application from any liability associated with the disclosure of confidential or privileged medical/healthcare information. I understand that the County of Arlington cannot properly evaluate my request for accommodation unless I sign this release and that any information disclosed under this release could potentially be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations.

*

By checking this box and typing my name below, I am electronically signing my application. *

Type Name *

Name

Sig Date *

Date

ADA Accommodation Request

Your Information

ADA Accommodation Request

Information about your Accommodation

ADA Accommodation Request

Information about your Accommodation

ADA Accommodation Request

Upload Documentation

ADA Accommodation Request

Acknowledgements and Submission

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