Employee Accommodation Request Form

*** FOR USE BY NDOT EMPLOYEES ONLY ***

Employees may use this form to request for an accommodation under the Americans with Disabilities Act (ADA). An accommodation is a reasonable modification or adjustment to the work environment that enables a qualified person with a disability to perform the essential functions of a position, or enjoy the same benefits and privileges of employment as are enjoyed by non-disabled employees. In order to determine whether you are eligible for an accommodation under the ADA, you may be asked for documentation of your medical condition. Employees may contact Human Resources at 402-479-3110 to request an accommodation.

CONFIDENTIALITY

The ADA requires that the agency keep medical information confidential. However, the law allows the agency to share information regarding your medical condition with individuals who are considered to have a legitimate need to know this information. These persons can include your supervisor(s), Human Resources Division personnel, first-aid and safety personnel, personnel investigating compliance with the ADA, and other persons considered to have a legitimate need to know. The law does not prohibit you from voluntarily discussing your condition or medical information with others.

SECTION I.

EMPLOYEE INFORMATION

(Please print, type, or complete “online”)

Date Requested:
Employee Name:
Division/District:
Job Title:
Supervisor:
Employee’s Telephone No.:	Supervisor’s Telephone No.:

NDOT Form 55, June 2023	(Continued)

ACCOMMODATION REQUEST DETAILS

1.	Please describe the medical condition for which you are requesting an accommodation:

(Attach additional pages, if necessary.)

2.	Please explain how the medical condition affects your ability to perform your job:

(Attach additional pages, if necessary.)

3.	Please describe the reasonable accommodation you are requesting:

(Attach additional pages, if necessary.)

Employee Signature	Date of Request

PLEASE SUBMIT COMPLETED FORM TO:

Nebraska Department of Transportation

Human Resources Division

1500 Nebraska Parkway

PO Box 94759

Lincoln NE 68509-4759

FOR HUMAN RESOURCES DIVISION USE ONLY

Date Received	Received By
Date of Reply