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Reasonable Accommodation Request Form

PERSONAL INFORMATION NOTICE


Pursuant to the Federal Privacy Act (P.L.93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The requested personal information is voluntary. The principle purpose of the voluntary information is to facilitate the processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your ADA Coordinator, Kenneth W. Fleming

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- This link downloads Reasonable Accommodation Request Form in MS Word format (DOC)

- This link downloads Reasonable Accommodation Request Form in Rich Text format (RTF)

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