Note to employers: This questionnaire serves as a basic tool for an employer's determination of compliance with Title I of the Americans with Disabilities Act (ADA), as amended. If your state's disability protection provisions for employment differ from the federal law and regulations, you will need to complete additional steps. For complex ADA situations and determinations, SHRM strongly recommends that employers obtain legal counsel review.
Title I of the ADA prohibits discrimination against qualified individuals with disabilities in job application procedures, hiring, firing, advancement, compensation, job training and other terms, conditions and privileges of employment.
Individual Name (Applicant or Employee):
Position:
Department:
Supervisor:
Completed by:
Date Completed:
1. Is the Employer Covered?
An employer covered by the ADA is a person or entity engaged in an industry affecting commerce with 15 or more employees for each working day in each of 20 or more calendar weeks in the current or preceding calendar year. The ADA also covers state and local governments, employment agencies, and labor organizations. The ADA's nondiscrimination standards apply to federal-sector employees under section 501 of the Rehabilitation Act.
Is the employer covered? __ Yes ___ No
2. Has the Individual Provided Notification to the Employer of the Need for Accommodation?
The Equal Employment Opportunity Commission (EEOC) states that an employer generally does not have to provide a reasonable accommodation unless an individual with a disability has asked for one. A request can be a statement in "plain English" that an individual needs an adjustment or change in the application process or at work for a reason related to a medical condition. The request does not have to include the terms "ADA" or "reasonable accommodation," and the request does not have to be in writing, although the employer may ask for written documentation. A family member, friend, health professional, rehabilitation counselor or other representative also may request a reasonable accommodation on behalf of an individual with a disability.
Has the individual provided information that a job modification is needed due to a medical condition that may qualify as a disability under the ADA or provided other information to start the ADA process? ___ Yes ___ No
An employer should initiate discussions regarding necessary reasonable accommodations without being asked when:
- The employer knows that the employee has a disability.
- The employer knows, or has reason to know, that the employee is experiencing workplace problems because of the disability.
- The employer knows, or has reason to know, that the disability prevents the employee from requesting a reasonable accommodation.
If the individual with a disability states that he or she does not need a reasonable accommodation, the employer will have fulfilled its obligation.
3. Is the Individual Qualified as Defined by the ADA?
The ADA "prohibits discrimination against qualified individuals with disabilities." As defined by the ADA, a qualified individual with a disability is 1) an individual with a disability who satisfies the requisite skill, experience, education and other job-related requirements of the employment position such individual holds or desires, and 2) an individual who, with or without reasonable accommodation, can perform the essential functions of such position.
Does the individual have the requisite skills, experience and education, and does he or she meet other job-related requirements? ___ Yes ___No
Describe how this determination is made:
Can the individual who desires or holds the position perform the essential functions of the job with or without an accommodation? ___ Yes ___No
What are the essential functions of the job?
How are these documented? If by a job description, attach the description.
4. Does the Individual Have a Disability as Defined by the ADA?
The ADA defines an individual with a disability as a person who:
- Has a physical or mental impairment that substantially limits one or more major life activities.
- Has a record of such an impairment.
- Is regarded as having such an impairment.
The employer needs to separate the three parts of this definition and review the definition of each to determine whether the individual has a disability as defined by the ADA. The three components of the definition are listed below.
1. Has a physical or mental impairment that substantially limits one or more major life activities.
"Physical or mental impairment" means:
Any physiological disorder or condition, cosmetic disfigurement or anatomical loss affecting one or more of the following body systems: neurological, musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine; or
Any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.
Exceptions: The terms "disability" and "qualified individual with a disability" do not include individuals currently engaging in the illegal use of drugs, when the covered entity acts based on such use. However, the terms "disability" and "qualified individual with a disability" may not exclude an individual who:
- Has successfully completed a supervised drug rehabilitation program and is no longer engaging in the illegal use of drugs, or has otherwise been rehabilitated successfully and is no longer engaging in the illegal use of drugs; or
- Is participating in a supervised rehabilitation program and is no longer engaging in such use; or
- Is erroneously regarded as engaging in such use but is not engaging in such use.
EEOC guidance on drug and alcohol use:
Current illegal use of drugs is not protected by the ADA. An employer does not need to hire or retain someone who is currently engaging in the illegal use of drugs. Tests for the current illegal use of drugs are permitted at any time prior to or during employment.
While people with alcoholism may be individuals with disabilities, the ADA still allows employers to hold them to the same performance and conduct standards as all other employees, including rules prohibiting drinking on the job.
Also, disability does not include:
- Transvestism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments, or other sexual behavior disorders.
- Compulsive gambling, kleptomania or pyromania.
- Psychoactive substance use disorders resulting from current illegal use of drugs.
- Homosexuality and bisexuality.
"Major life activities," as defined by the ADA, include:
- Caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, interacting with others, and working; and
- The operation of a major bodily function, including functions of the immune system, special sense organs and skin; normal cell growth; and digestive, genitourinary, bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, hemic, lymphatic, musculoskeletal, and reproductive functions. The operation of a major bodily function includes the operation of an individual organ within a body system.
The term "substantially limits" means:
An impairment is a disability if it substantially limits the ability of an individual to perform a major life activity as compared to most people in the general population. An impairment need not prevent, or significantly or severely restrict, the individual from performing a major life activity to be considered substantially limiting.
Based on the criteria above, does the individual have a physical or mental impairment that substantially limits one or more major life activities? ___ Yes ___ No
Describe the impairment:
List the major life activity or activities that are substantially limited:
2. "Has a record of such an impairment" means:
The individual has a history of, or has been misclassified as having, a mental or physical impairment that substantially limits one or more major life activities.
Does the individual have a record of such an impairment? ___ Yes ___ No
Describe:
3. "Is regarded as having such an impairment" means:
- Has a physical or mental impairment that does not substantially limit major life activities but is treated by a covered entity as constituting such limitation.
- Has a physical or mental impairment that substantially limits major life activities only as a result of the attitudes of others toward such impairment.
- Has none of the impairments defined in this section but is treated by a covered entity as having a substantially limiting impairment.
Is the individual regarded as having such an impairment? ___ Yes ___ No
Describe:
5. What Are the Reasonable Accommodation Considerations for the Individual?
The ADA defines a "reasonable accommodation" as:
- Modifications or adjustments that enable a qualified applicant with a disability to be considered for the position such qualified applicant desires.
- Modifications or adjustments to the work environment, or to the manner or circumstances under which the position held or desired is customarily performed, that enable a qualified individual with a disability to perform the essential functions of that position.
- Modifications or adjustments that enable a covered entity's employee with a disability to enjoy equal benefits and privileges of employment as are enjoyed by its other similarly situated employees without disabilities.
Reasonable accommodations may include but are not limited to:
- Existing facilities used by employees being made readily accessible to and usable by individuals with disabilities.
- Job restructuring.
- Part-time or modified work schedules.
- Reassignment to a vacant position.
- Telework.
- Acquisition of or modifications to equipment or devices.
- Appropriate adjustment or modifications of examinations, training materials or policies.
- The provision of qualified readers or interpreters.
To determine the appropriate reasonable accommodation, employers should initiate an informal, interactive process with the individual. This process should identify the precise limitations resulting from the disability and potential reasonable accommodations that could overcome those limitations.
What is the accommodation the individual requested?
Describe:
The ADA defines undue hardship as significant difficulty or expense incurred by a covered entity, considering the following factors:
- The nature and cost of the accommodation needed.
- The overall financial resources of the facility making the reasonable accommodation; the number of persons employed at this facility; and the effect on expenses and resources of the facility.
- The overall financial resources, size, number of employees, and type and location of facilities of the employer (if the facility involved in the reasonable accommodation is part of a larger entity).
- The type of operation of the employer, including the structure and functions of the workforce, the geographic separateness, and the administrative or fiscal relationship of the facility involved in making the accommodation to the employer.
- The impact of the accommodation on the operation of the facility.
Is this a reasonable accommodation that does not impose an undue hardship on the employer? ___ Yes ____ No
If no, describe the evidence to support undue hardship:
In addition to actions that would result in undue hardship, the employer does not have to do any of the following:
- Provide an employee with an adjustment or modification that would assist the individual both on and off the job, such as a prosthetic limb, wheelchair or eyeglasses.
- Remove or alter a job's essential functions.
- Lower production or performance standards.
- Excuse violations of conduct rules necessary for the operation of the business.
6. Has the Employer Provided the Reasonable Accommodation?
___ Yes __ No (description included in question above pertaining to undue hardship)
Describe the accommodation provided:
Date accommodation was provided:
Describe documentation of the accommodation:
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