Accommodations Form

Better Living will promote accessibility, by removing identified barriers for people with disabilities and providing services, programs, and activities to individuals with disabilities in the most integrated setting appropriate to meet their needs within the context of the program, service, or activity being administered, as required by the Americans with Disability Act and the Rehabilitation Act (ADA). It is the intention of Better Living to comply with the ADA in the provision of an accessible facility and safe environment for persons served, employees, stakeholders, and visitors.

Employees, persons served, stakeholders, and visitors may make a request to a Better Living supervisor, Leadership member, or the HR department or by submitting this form. You may be asked to submit information to support the request from a physician or other appropriate source. When possible, if reasonable accommodations are not able to be granted, efforts will be made to provide services in a more suitable setting based on needs. Once the form and information are submitted, someone will get back to you within 7 working days.

Name

First Name

Last Name

Phone

(###)

###

####

Date

YYYY

Supervisor or Better Living Contact

Nature of qualifying disability

(if applicable; describe the nature, extent, and duration of your disability)

Physician contact information (if applicable)

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Fax

(###)

###

####

Requested accommodation (job change, change in assigned duties, schedule change, dress/appearance code exception, workplace or service change, lactation need, etc.)

The physician may receive a letter/fax from us requesting information on your impairment/disability and recommendations for accommodations.

Length of time accommodation is needed

Describe any alternate accommodations that might address your need(s)

Accommodations Form

Considering Becoming a Foster Parent?