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AmeriCorps Partners in Learning - Reasonable Accomodation Form

  1. Reasonable Accommodation Form

    As a program that receives federal funds, AmeriCorps Partners in Learning Program complies with the requirements of the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act. No qualified individual with a disability shall, by reason of disability, be excluded from participation in or be denied the benefits of the program, services, or activities of the program, or be subjected to discrimination by the program. Nor shall the program exclude or otherwise deny equal services, programs or activities to an individual because of a disability. The program shall make reasonable accommodations in policies, practices, or procedures when the accommodations are necessary to avoid discrimination on the basis of disability, unless the program can demonstrate that making the modifications would fundamentally alter the nature of the service, program, or activity, and/or impose an “undue hardship”. A reasonable accommodation may include: making facilities readily accessible to and usable by individuals with disabilities; job restructuring; part-time or modified schedules; acquisition or modification of equipment or devices, training materials, or policies; etc. ​Members may request reasonable accommodations by completing the Reasonable Accommodation Request Form and submitting it to the program director through the form below. ​Confidentiality: Information provided regarding her/his disability, by a potential member or a member shall be kept confidential, except that appropriate supervisors, managers, and safety and health personnel may be informed regarding any restrictions in service duties or necessary accommodations. Government personnel may be provided information in compliance with various laws and regulations. Self-Identification: A potential member or a member with a disability is not required to disclose information about any physical or mental limitations, whether or not you believe it will interfere with your capability to perform the essential functions of the position sought or held. If you would like, however, for the program, to consider any special arrangements to accommodate a physical or mental impairment, you may identify that impairment, describe the functional limitations that result from that impairment, and suggest the type of accommodation that you believe would be appropriate. Medical verification of the condition may be requested for the member to be protected under Section 504 of the Rehabilitation Act. Grievances: An individual whose request for an accommodation was denied may use the grievance procedure outlined in the Member Service Agreement to appeal the decision and/or file a complaint with the Corporation for National and Community Service Equal Opportunity Office within forty-five days of the decision or forty-five days from when the member becomes aware of the decision.

  2. Please describe the nature, extent, and duration of your disability.

  3. Please describe the accommodations you believe are needed to enable you to perform the essential functions of this job.

  4. Please provide name, address, telephone. The physician may receive a letter/fax from us requesting information on your impairment/disability and recommendations for accommodations.

  5. Thank you for submitting this form.

    ​Confidentiality: Information provided regarding her/his disability, by a potential member or a member shall be kept confidential, except that appropriate supervisors, managers, and safety and health personnel may be informed regarding any restrictions in service duties or necessary accommodations. Government personnel may be provided information in compliance with various laws and regulations.

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  7. This field is not part of the form submission.