Request for Reasonable Accommodation

Claimant Name: Thomas D Coates
Employee Number: *****9495
Date of Birth: 12/29/1965
Home Address: 3416 Warren Place Apt 201, Virginia Beach, VA 23452
Home #: 757 3743539
E-Mail: thomas.coates@cox.com
Avg. Weekly Scheduled Work Hours: 40.0
Employment Type: Full Time
Employment Status: Active
Union/Non-Union: N
Employee Tier: 1
Job Description: S1181
Original Date of Hire: 11/27/2023
Date of Hire: 11/27/2023
Customer Information: 239762220218327
Report #: 0317402
Work Location: HAMP0024
Work State: VA
Level 1 Supervisor:
    Name: Holmes, Donte
    Job Description: M2075
    E-Mail: Donte.Holmes@cox.com

SECTION I: REQUESTOR INFORMATION

Assistance Needed: (Check One)
Performing Job Functions or Accessing Work Environment
First Name:
Last Name:
Current Employees Only
Office or Division Assignment:
Office Location:
Position Classification:
Position Title:
Work Location or Office Address:
Work Telephone:
Personal Telephone:
Email Address:
Supervisor's Name:
Supervisor’s Telephone:
Applicants, Employees On Full-Time Telework, or Employees On Extended Leave
Home Address:
Personal Telephone:
Job Vacancy Number:

SECTION II. ACCOMMODATION REQUESTED

What specific accommodation are you requesting?

Flexible Work Schedule to Accommodate Medical Needs:
In collaboration with my supervisor, I request a flexible work schedule that accommodates my scheduled medications and doctor's appointments. This may include adjusted start and end times or a compressed workweek.
Additionally:
I would like to inquire about the possibility of having a list of nearby medical facilities, including doctors' offices and cardiologists, readily available for my reference, in case of emergencies or urgent needs.
By including the request for a flexible schedule and information on nearby medical facilities, you address both your need to manage medications and access healthcare providers while working remotely. Remember to provide any relevant documentation from your doctor to support your requests.

I formally request authorization to work remotely from my home office. This will allow me to manage my health conditions (anxiety, depression, heart disease, thyroid) more effectively while fulfilling all my job duties.

I request secure remote access to all essential work systems, including payroll, corporate network systems, and any other platforms required to perform my job functions effectively.

To ensure efficient and compliant remote work, I request all remote access tools and protocols for secure system usage. This includes clear instructions on accessing payroll systems and other relevant software.

I request access to easily understood and accessible training materials on all company compliance policies and procedures.

To facilitate seamless remote work, I request regular and interactive communication with my supervisor. This includes clear instructions on deadlines, expectations, and open communication channels to address any challenges arising while working remotely.

To optimize my remote work experience and address potential limitations, I request collaborative exploration with the IT department to determine if any assistive technology software can further enhance my ability to access and interact with work systems which may include.

To reduce distractions and anxiety in my home workspace, I request access to noise-cancelling headphones. This will allow me to concentrate on work tasks effectively.

Regular Check-ins and Feedback Sessions:
To ensure my remote work performance meets expectations and to identify any potential obstacles, I request regular check-ins and feedback sessions with my supervisor. This open communication will allow for adjustments as needed to maintain productivity and compliance.
By making these specific requests, you clearly communicate your needs for a successful remote work arrangement while managing your health conditions. Remember to keep communication open with your employer throughout the process.

If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore? Yes No
If yes, please explain.

Date Request for Reasonable Accommodation Needed:
Is your accommodation request time sensitive? Yes No
If yes, please explain.

ACCOMMODATION REQUEST

Do you currently use any accommodation? Yes No
If yes, list accommodations:

Accommodation(s) Requested (please specify):
Assistive Technology
Alternative Work Schedule
Ergonomic Equipment
Service (e.g., SLI, reader, note taker)
Telework
Workspace Modification
Other
Not Sure

SECTION III. REASON FOR REQUEST

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

What, if any, employment benefit are you having difficulty accessing?

What limitation is interfering with your ability to perform your job or access an employment benefit?

Have you had any accommodations in the past for this same limitation? Yes No
If yes, what were they and how effective were they?

If you are requesting a specific accommodation, how will that accommodation assist you?

SECTION IV. OTHER

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

I acknowledge that I may be required to submit medical documentation from my healthcare provider to support my request.
Signature:
Date:

Important Note:

Employers may mistakenly discontinue the interactive process when an employee requests an accommodation that is not effective, would be too difficult, or is not legally required. However, the interactive process is an ongoing dialogue between the employer and employee that aims to remove barriers so that employees can perform their jobs with accommodations. If an employer doesn't continue the process, they may be violating the Americans with Disabilities Act (ADA). Courts will rule against the party that prevents the process from continuing, and the U.S. Equal Employment Opportunity Commission (EEOC) also prefers to see employers actively engaged. The state may also require employers to participate in the process in good faith and in a timely manner.