ADA Request Form

The Personnel Board of Jefferson County ADA Accomodation Request

The Personnel Board of Jefferson County is an equal opportunity employer and does not unlawfully discriminate on the basis of race, sex, religion, age, national origin, veteran status, or disability. This form is used to submit requests for accommodation in the testing process for qualified individuals with disabilities. This document must be completed, either by the applicant or by the ADA Ombudsman, in order for a request for accommodation to be considered. If you need assistance in completing this form, please contact the ADA Ombudsman at 279-3582 or 279-3595. Every request for accommodation will receive individual consideration on its own facts and circumstances.

Applicant Name *

Job Applied For *

Home Phone *

Alternate Phone

Email

Mailing Address *

Nature of Disability:
Please describe your specific disability in enough detail to enable the ADA Ombudsman to determine whether you have a qualifying disability, whether an accommodation is necessary, and if so, what accommodations are appropriate. Please include specific information about how your disability impairs the performance of the activities that will be part of the testing process.

Accommodation Requested:
Please specify the accommodation that you believe would be reasonable and would effectively accommodate your disability. If there are other possible alternative accommodations, please list them as well.

Certification
By submitting this form you certify that all of the information provided on this form is true. Under PBJC Rules 9.5(c), 9.14, and 12.1, any material misrepresentation on this form could result in your disqualification from the competitive testing process, and/or disciplinary action.