Reasonable Accommodation Request Form and Authorization to Solicit Medical Information[Digital]

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By checking this box, I authorize the University of Puerto Rico Mayagüez Campus, the College of Agricultural Sciences’ EEO/ADA Office and its Reasonable Accommodation Committee to solicit and obtain all the medical information needed, from both private physicians and the State Insurance Fund Corporation, related to my case. This information will be used to assess whether the condition or impairment meets the requirements of the American with Disabilities Act (ADA of 1990), as amended, for a reasonable accommodation. I voluntarily agree to submit all the evidence required to be able to evaluate my case. I certify that I was informed on the procedure for the evaluation of reasonable accommodation cases, according to Certification No. 01-02-180, of September 18, 2001, of Mayagüez Campus’ Administrative Board, and on the confidentiality of this matter.(Required)
This field is for validation purposes and should be left unchanged.

Reasonable Accommodation Request Form and Authorization to Solicit Medical Information[Digital]

MM slash DD slash YYYY
By checking this box, I authorize the University of Puerto Rico Mayagüez Campus, the College of Agricultural Sciences’ EEO/ADA Office and its Reasonable Accommodation Committee to solicit and obtain all the medical information needed, from both private physicians and the State Insurance Fund Corporation, related to my case. This information will be used to assess whether the condition or impairment meets the requirements of the American with Disabilities Act (ADA of 1990), as amended, for a reasonable accommodation. I voluntarily agree to submit all the evidence required to be able to evaluate my case. I certify that I was informed on the procedure for the evaluation of reasonable accommodation cases, according to Certification No. 01-02-180, of September 18, 2001, of Mayagüez Campus’ Administrative Board, and on the confidentiality of this matter.(Required)
This field is for validation purposes and should be left unchanged.