Accommodation Request Form

Ampact is committed to the full inclusion of all qualified individuals. As part of this commitment, we will ensure that persons with disabilities or persons needing a religious accommodation are provided reasonable accommodations. An accommodation is a modification or adjustment to a job application, interview process, job duties or the work environment to allow an individual to perform the essential functions of the position.

This form will be used as an initial review for your accommodation request. This is an interactive process to ensure the needs of members, sites, and employees of the organization are considered.  In some cases, we may need to consult additional individuals in the process such as site staff. Information will only be shared that is pertinent to reviewing and assessing the request. For the full Disability Accommodtions Policy, please click here.

Please complete the information below to the best of your knowledge.  After submitting this request, it will be reviewed by our Accommodations Coordinator who will reach out for additional information or to follow-up.

If you need assistance completing this form, please contact accommodations@ampact.us.

Section 1: General Information

Are you completing this request for yourself or on behalf of someone else? *

Do you, or the individual you are filling this form out for, need an accommodation? *

If you are completing on someone else's behalf, what is your name? *

If you are completing on someone else's behalf, what is your email address? *

If you are completing this form on someone else's behalf, please fill out the remaining questions with that individual's information rather than your own.

First Name *

Last Name *

Email *

Phone *

What is your preferred name? (if different from above)

What are your pronouns? (optional)

Preferred Contact Method *

Current Role *

Is this request needed in the next 7 days? *

Yes

No

Section 2: Request Information

Please check here if you have submitted an accommodation request to our organization during a previous application process or while serving in a different role. The request details below will be made optional and we will reference your previous submission.

Yes, I have submitted a request for an accommodation or work adjustment at this organization before.

Do you have a disability? A disability is a physical or mental impairment that substantially limits one or more major life activities? *

Yes

No

If you would prefer to discuss your request over the phone rather than completing the rest of the form, please indicate here.

I would prefer to discuss this request over the phone.

Explain how your condition limits your ability to perform the essential functions of your position or the position for which you are applying: *

Describe the accommodations you believe are needed to enable you to perform the essential functions of this job. *

If you are not sure what accommodation is needed, what options should be explored?

Anticipated length of time the accommodation is needed *

Short Term (1-12 weeks)

Year Long (12+ weeks)

Undetermined

Where do you anticipate needing this accommodation? (Check all that apply) *

Interview

Training

Work or Service Site

Other Other

[Optional] Please attach any supporting documentation that may be helpful in evaluating this request for accommodation. Additional documentation may be necessary later as we review the request.

If you don't have a disability but require some other work adjustment to enable you to perform your job, please describe it here. *

If you do not require an accommodation, you do not need to submit this form. Please close this window or tab to cancel this request.

Section 3: Acknowledgement

I acknowledge the above information may be shared with staff or partners as necessary to consider or implement the accommodation. *

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