Fairfax County Public Schools Disability Accommodation Request
This document serves as a request for reasonable accommodations for employees with disabilities. It includes essential information for filing for disability benefits and medical support. Employees should complete this form to ensure proper consideration of their needs.
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How do I fill this out?
To fill out this form, begin by providing your personal information in the designated fields. Next, detail your disability or impairment briefly. Finally, check the benefits you intend to apply for or are currently receiving.
How to fill out the Fairfax County Public Schools Disability Accommodation Request?
1
Start by entering your personal and work information.
2
Describe your medical condition clearly and concisely.
3
Indicate any benefits you wish to apply for.
4
Sign and date the form to validate your request.
5
Submit the completed form to the appropriate offices.
Who needs the Fairfax County Public Schools Disability Accommodation Request?
1
Employees who have sustained a work-related injury and need to request accommodations.
2
Individuals currently receiving disability benefits and need to provide updates.
3
New employees with disabilities needing necessary accommodations.
4
Employees looking to apply for Family Medical Leave Act (FMLA) benefits.
5
Team members requiring clarification on their rights under the Americans with Disabilities Act (ADA).
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What are the instructions for submitting this form?
Submit the completed accommodation request form to the Office of Equity & Employee Relations via fax at 571-423-5051 or email at EERADA@fcps.edu. For Short-Term Disability claims, send it to Sedgwick at 859-264-4384 or email claiminfo@sedgwickcms.com. Ensure your documentation is included and keep copies of submissions for your records.
What are the important dates for this form in 2024 and 2025?
Important dates to consider are the deadlines for filing benefits claims and submitting accommodation requests, typically set by your HR department. Ensure to check for annual policy reviews or updates that may affect your submission. Staying informed will help ensure timely processing of your requests.
What is the purpose of this form?
The purpose of this form is to ensure Fairfax County Public Schools provides necessary accommodations to employees with disabilities. It supports compliance with legal requirements under the Americans with Disabilities Act (ADA) and facilitates access to benefits. By completing this form, employees can improve their work environment and overall job satisfaction.
Tell me about this form and its components and fields line-by-line.
- 1. Employee Information: Personal and employment details of the employee including name, position, and contact information.
- 2. Nature of Disability: Details about the employee's medical condition or impairment.
- 3. Benefit Selection: Options to select the type of benefits applied for or received.
- 4. Medical Provider Section: A section to be completed by the treating medical provider outlining the employee's condition.
- 5. Signature and Submission: Area for the employee to sign and date the form before submission.
What happens if I fail to submit this form?
Failure to submit this form can result in delays in obtaining necessary accommodations or benefits. It may also lead to potential non-compliance with ADA requirements. Employees are encouraged to submit all required information to avoid issues.
- Delay in Benefits: If the form is not submitted, employees may face delays in receiving short-term or long-term disability benefits.
- Loss of Accommodations: Without submission, accommodations required for the employee's role may not be provided.
- Non-compliance Issues: Failure to submit the form may lead to violations of ADA regulations.
How do I know when to use this form?
- 1. Requesting Accommodations: When an employee needs adjustments in their work environment due to a disability.
- 2. Applying for Disability Benefits: To apply for short-term or long-term disability benefits.
- 3. Informing about Medical Conditions: To update the employer regarding any medical concerns that affect work.
Frequently Asked Question
How do I fill out the accommodation request form?
Begin by entering your personal details, describe your disability, and indicate any benefits you may apply for.
Can I save the changes I make to this PDF?
You can download your edited PDF after making changes, but saving is not available.
What if I need help with my request?
Consult the human resources department or the Equity & Employee Relations office for assistance.
Is there a deadline for submitting this form?
Please refer to your company's policy regarding deadlines for disability accommodation requests.
What documents do I need to submit with this form?
You may need to include medical documentation and any previous benefit claims.
Where do I submit my completed form?
Submit it to the Office of Equity & Employee Relations, or directly to Sedgwick or MetLife.
What if my medical condition changes?
You should update the form and resubmit it if your condition changes.
What are the available benefits I can apply for?
Check the form for options like Short-Term Disability, Long-Term Disability, and Workers' Compensation.
How often can I request for accommodations?
You can request accommodations as needed, especially if your circumstances change.
Can I fill out this form electronically?
Yes, you can fill it out using an online PDF editor.
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