[{"id":"85519211-7b53-4609-8c95-c65bda1462dd","order":1,"text":"[Employer / Company Name]","fontSize":"16","textAlign":"center","bold":true,"underline":false,"marginBottom":"2","cflou":false,"active":true},{"id":"7ad9085b-6c83-4e34-ab09-cd226161fd19","order":2,"text":"[Street Address]
[City, State, ZIP]","fontSize":"11","textAlign":"center","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"a1a66be7-397e-40f6-838c-b043c07641ec","order":3,"text":"REASONABLE ACCOMMODATION REQUEST AND DETERMINATION FORM","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"417628c0-fbf7-4395-af46-403fa04e1f5e","order":4,"text":"Americans with Disabilities Act (ADA) & ADA Amendments Act of 2008 (ADAAA)","fontSize":"12","textAlign":"center","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"83d5abc0-8404-44ba-a0c6-f9a543ad2c6b","order":5,"text":"Confidential Personnel Record — Maintained Separately From the General Personnel File","fontSize":"11","textAlign":"center","bold":true,"underline":false,"marginBottom":"24","cflou":false,"active":true},{"id":"9c73a2a6-bbf5-4141-bd42-4dbe76715254","order":6,"text":"1. PURPOSE AND LEGAL FRAMEWORK","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S01"},{"id":"d7c8ef22-9096-461a-8d9c-1fe8b5e976e8","order":7,"text":"This form is used to document a request for a reasonable accommodation under Title I of the Americans with Disabilities Act of 1990, as amended by the ADA Amendments Act of 2008 (42 U.S.C. § 12101 et seq.), and the regulations of the U.S. Equal Employment Opportunity Commission (29 C.F.R. Part 1630), together with any applicable state or local disability-rights law that provides equal or greater protection.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"083469e0-8f86-411a-95ad-2aa353e6313a","order":8,"text":"A reasonable accommodation is any change to the application process, the work environment, or the manner in which a job is customarily performed that enables a qualified individual with a disability to apply for a position, to perform the essential functions of a position, or to enjoy equal benefits and privileges of employment. The Employer engages in this process in good faith and on an individualized, case-by-case basis.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"970ba1fa-c868-47fc-898a-741ba0bb2901","order":9,"text":"Completion of this form initiates or documents the interactive process between the Employer and the requesting individual. The Employer is not required to provide the specific accommodation requested, to eliminate an essential job function, to lower production or performance standards, or to provide an accommodation that would impose an undue hardship; it must, however, provide an effective accommodation absent undue hardship.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true},{"id":"75b65051-f148-4392-b9a3-1e373cfe545b","order":10,"text":"2. INFORMATION REGARDING THE REQUESTING INDIVIDUAL","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S02"},{"id":"c74c9bcc-41b4-4307-8854-19fdf6511e60","order":11,"text":"The individual requesting an accommodation (the “Requestor”) is an employee of the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"ee464d3b-dae3-4250-a1f9-973b905d51e5","order":12,"text":"Name: [Full Legal Name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"6bce6733-63da-4d89-887c-dbc697a7b75e","order":13,"text":"Address: [Residential Address], [City, State, ZIP]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"e76a492c-506c-4091-abbf-921c74797a52","order":14,"text":"Email: [Email Address] | Telephone: [Telephone]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"ada36082-3e76-4614-b38c-144da893a4aa","order":15,"text":"Employee Identification Number: [Employee ID / Payroll No.]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"aa32322b-b129-4e42-99ae-2a30557d73c7","value":"an applicant for employment","type":"remove","operator":"="}]},{"id":"331ba4f2-5bb4-4aa0-8d30-45a60e763d7a","order":16,"text":"As an applicant, the Requestor seeks an accommodation in connection with the application, testing, or interview process, or to enable performance of the essential functions of the position sought.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"aa32322b-b129-4e42-99ae-2a30557d73c7","value":"an applicant for employment","type":"add","operator":"="}]},{"id":"4c4b1898-d367-49b1-a5fe-420d70b4174e","order":17,"text":"3. POSITION AND EMPLOYMENT INFORMATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S03"},{"id":"69bd6478-502e-4500-811c-3e474e344be7","order":18,"text":"Position / Job Title: [Position / Job Title]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"72bd4d5e-04cb-4d0c-8e5e-a9e4bbef7496","order":19,"text":"Department or Division: [Department / Division]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"6089c7df-da29-403c-8d59-fc20a457da13","order":20,"text":"Immediate Supervisor or Manager: [Supervisor / Manager]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"8dc8188e-e544-43bf-a889-fcfada133ff0","order":21,"text":"Work Location or Worksite: [Work Location / Worksite]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"3b8b3812-7592-49b9-ab24-ec69261274e2","order":22,"text":"Date of Hire: [Date of Hire] | Employment Status: Full-time","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"aa32322b-b129-4e42-99ae-2a30557d73c7","value":"an applicant for employment","type":"remove","operator":"="}]},{"id":"2a0d351d-dbff-4334-bc79-c49e030681af","order":23,"text":"(Employment status and date of hire are not applicable, as the Requestor is an applicant for employment.)","fontSize":"11","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"aa32322b-b129-4e42-99ae-2a30557d73c7","value":"an applicant for employment","type":"add","operator":"="}]},{"id":"43927ba4-7dc4-4a44-b567-b900db3ffb81","order":24,"text":"4. NATURE OF THE LIMITATION REQUIRING ACCOMMODATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S04"},{"id":"c0d5ba74-4896-4289-9d0e-59dba0ca18d1","order":25,"text":"The Requestor has a physical or mental impairment that substantially limits one or more major life activities, has a record of such an impairment, or is otherwise a qualified individual entitled to accommodation. The Requestor is not required to disclose a specific diagnosis; the following describes the functional limitation(s) and the work-related barrier(s) for which an accommodation is sought:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"7b692674-31f7-45ec-a699-b7b6351584a6","order":26,"text":"[Description of functional limitations and barriers]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"4dba977a-cd22-4ec3-b0fb-eec583be581c","order":27,"text":"This information is collected solely to evaluate the accommodation request and is maintained as a confidential medical record in accordance with 29 C.F.R. § 1630.14(c).","fontSize":"11","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true},{"id":"06f988ff-7f7b-4365-8283-7f2420b8ab84","order":28,"text":"5. ACCOMMODATION REQUESTED","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S05"},{"id":"8f3579a5-c991-4f9a-bf9e-d3746ac49252","order":29,"text":"The Requestor requests the following accommodation: [Description of the accommodation requested]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"a63d9f51-b23c-49e8-adf7-90d9e4d76bd1","order":30,"text":"Requested effective date of the accommodation: [Requested effective date]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"627c91c3-9c26-49e8-b434-476dd1590a2b","order":31,"text":"Anticipated duration of the accommodation: Ongoing / indefinite.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"d12e0a87-118e-4a7f-82ad-a70a5b08da5b","order":32,"text":"If temporary, the accommodation is anticipated to remain in effect until [Anticipated end date], subject to review and extension as warranted.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"7d11e276-985f-46dd-ad7f-bdcf63d78784","value":"Temporary / time-limited","type":"add","operator":"="}]},{"id":"7b11f6b8-9f30-4d15-9ac7-c7f51c5b7dde","order":33,"text":"6. ESSENTIAL JOB FUNCTIONS AND IMPACT","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S06"},{"id":"20300426-8b81-4f5a-b954-aa08e2256669","order":34,"text":"The essential functions of the position affected by the limitation, and the manner in which the requested accommodation would enable the Requestor to perform those functions, are described below:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"1d16dc82-47c8-4e39-8f72-47b2fa27e1fb","order":35,"text":"[Essential functions affected and expected effect of the accommodation]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"8ad3a150-97a9-4e1e-98d9-700567558e06","order":36,"text":"Marginal functions and non-essential tasks have been considered separately and may be reassigned where appropriate; the elimination of an essential function is not required as an accommodation.","fontSize":"11","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true},{"id":"646bac67-36f6-4a4d-9994-0e00b0274c00","order":37,"text":"7. SUPPORTING MEDICAL DOCUMENTATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S07"},{"id":"ade5991e-e6e1-4434-9df0-05d04976a07c","order":38,"text":"Where the disability or the need for accommodation is not obvious or already known, the Employer may request reasonable documentation from an appropriate health-care or rehabilitation professional confirming the existence of a covered condition and the need for the requested accommodation, limited to information necessary for that purpose. The status of supporting documentation for this request is as follows:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"87a47c04-c1e9-4704-9745-5c2702f5f769","order":39,"text":"Documentation status: On file with the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"f249be05-0859-4515-9aed-3101e2cd037a","order":40,"text":"The Requestor is asked to obtain and submit supporting documentation from the following provider: [Health-care / treating provider].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"ad8eaf87-a3da-44a3-b78c-c9f39d987e99","value":"Requested from the Requestor","type":"add","operator":"="}]},{"id":"ad7caf3c-2a33-4705-98ff-534694897cf1","order":41,"text":"Such documentation is requested to be provided on or before [Documentation due date]. The interactive process will continue in the interim, and any reasonable delay by the provider will not be held against the Requestor.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"ad8eaf87-a3da-44a3-b78c-c9f39d987e99","value":"Requested from the Requestor","type":"add","operator":"="}]},{"id":"de13b792-6ae5-4e7c-8897-62dfe9926ddd","order":42,"text":"No supporting medical documentation is required, as the disability and the need for the requested accommodation are obvious or already known to the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"ad8eaf87-a3da-44a3-b78c-c9f39d987e99","value":"Not required (disability or need is known/obvious)","type":"add","operator":"="}]},{"id":"f2277156-400c-4bad-ac86-8362eba11cbb","order":43,"text":"8. THE INTERACTIVE PROCESS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S08"},{"id":"6ad06042-e8fb-42aa-ab9b-df7310ef078c","order":44,"text":"The Employer and the Requestor have engaged, or will engage, in a flexible, interactive process to identify the precise limitation, to explore potential accommodations, and to assess their effectiveness. Both parties agree to participate in good faith, to respond promptly to reasonable requests for information, and to communicate openly regarding the feasibility of any proposed accommodation.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"b0d74f46-38e5-4065-9014-f2fad2396db5","order":45,"text":"Date of the initial interactive-process discussion: [Date of interactive-process discussion]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"f82351c2-58be-497e-8d4f-43053e49e724","order":46,"text":"Participants: [Participants in the interactive process].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true},{"id":"7de62996-202f-478f-a097-a398d2b013fe","order":47,"text":"9. EMPLOYER DETERMINATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S09"},{"id":"7a49cc8f-3ae8-4ce5-8f2f-81818a0b638d","order":48,"text":"Having considered the request, the essential functions of the position, the available documentation, and the interactive process, the Employer’s determination is: Pending — under review.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"638824a4-9745-420c-9c79-f4d56f6ea544","order":49,"text":"The requested accommodation is approved on the following terms: [Approved terms and any conditions].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Granted as requested","type":"add","operator":"="}]},{"id":"6e5d4eea-ee7b-4d1f-add1-8d47171a83fb","order":50,"text":"The accommodation will be reviewed for continued effectiveness on or about [Scheduled review date], or sooner upon a material change in circumstances.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Granted as requested","type":"add","operator":"="}]},{"id":"a76465a6-8a2a-426d-a6f9-0504aa68e251","order":51,"text":"In lieu of the specific accommodation requested, the Employer offers the following alternative, which is intended to be equally effective in meeting the Requestor’s needs: [Alternative accommodation offered].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Granted in alternative form","type":"add","operator":"="}]},{"id":"6a3469dc-d279-41f9-aa80-865119424ccc","order":52,"text":"The rationale for offering this alternative is: [Rationale for the alternative]. The Requestor is invited to respond and to continue the interactive process.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Granted in alternative form","type":"add","operator":"="}]},{"id":"0ffb31a4-d7ae-459d-90a9-0529c697ef61","order":53,"text":"The request is denied. The principal basis for the denial is: Undue hardship.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Denied","type":"add","operator":"="}]},{"id":"411a997e-f304-454b-b306-4bfc0642e592","order":54,"text":"The specific facts and analysis supporting this determination are as follows: [Detailed explanation of the denial].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Denied","type":"add","operator":"="}]},{"id":"6679d4a3-c3f9-49e8-8f4e-32bb5d9d4718","order":55,"text":"This denial reflects an individualized assessment. The Requestor may submit additional information, propose alternative accommodations, or request reconsideration, and may pursue any rights available under applicable law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Denied","type":"add","operator":"="}]},{"id":"124671e8-8e59-4ea4-9af7-fc6702f91a9f","order":56,"text":"A final decision is pending the following: [Outstanding items required before a decision].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Pending — under review","type":"add","operator":"="}]},{"id":"e1518048-f4e0-481e-97b2-4b2d1ab38e98","order":57,"text":"The Employer will follow up with the Requestor on or about [Scheduled follow-up date] to complete the interactive process.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Pending — under review","type":"add","operator":"="}]},{"id":"aa1b2865-9baa-4b26-b778-0e0a19e85163","order":58,"text":"10. UNDUE HARDSHIP AND DIRECT-THREAT ANALYSIS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Denied","type":"add","operator":"="}],"sectionNum":"S10"},{"id":"ed005f40-9104-4f49-8df0-3bb9160c4bee","order":59,"text":"Where an accommodation is denied, the Employer has considered, as applicable, whether providing the accommodation would impose an undue hardship (significant difficulty or expense) in light of the nature and cost of the accommodation, the Employer’s overall financial resources, the size of the operation, and the impact on operations; and whether, despite reasonable accommodation, the individual would pose a direct threat to health or safety that cannot be eliminated or reduced by reasonable accommodation. The denial is supported by the explanation set forth in Section 9 above.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"4448d622-5aa3-404e-aeea-e30ed1332388","value":"Denied","type":"add","operator":"="}]},{"id":"33b6fa17-c52e-4f57-83d4-d01a544aa7cb","order":60,"text":"11. CONFIDENTIALITY AND RECORDKEEPING","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S11"},{"id":"0db4455a-80c2-4c83-8aef-b6d29b94d4b1","order":61,"text":"All medical information obtained in connection with this request is treated as a confidential medical record, maintained in files separate from the general personnel file, and disclosed only as permitted by 29 C.F.R. § 1630.14(c) — including to supervisors and managers regarding necessary work restrictions and accommodations, to first-aid and safety personnel where appropriate, and to government officials investigating compliance, or as otherwise required by law. Records relating to this request will be retained for the period required by applicable recordkeeping rules.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true},{"id":"124f924b-18c3-42a6-83c1-04419666ec22","order":62,"text":"12. NON-RETALIATION AND NON-INTERFERENCE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S12"},{"id":"e03bca02-eed0-44da-9617-7aa71b830beb","order":63,"text":"The Employer prohibits retaliation against any individual for requesting an accommodation, participating in the interactive process, or otherwise exercising rights under the ADA. No individual will be coerced, intimidated, threatened, or interfered with on account of having made such a request or assisted another in doing so.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true},{"id":"3d4fc759-d01d-48a7-8427-433d388a8f4d","order":64,"text":"13. ACKNOWLEDGEMENTS AND SIGNATURES","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"10","sectionNum":"S13"},{"id":"9bb60d7d-71df-4793-849c-904e5b8c0c7e","order":65,"text":"By signing below, the Requestor confirms that the information provided is accurate to the best of their knowledge and that they wish to engage in the interactive process. The Employer’s representative confirms that the request has been received and processed in accordance with this form and applicable law. Signature of this form does not, by itself, constitute approval or denial of any accommodation; the Employer’s determination is set forth in Section 9.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"96bf8314-6238-4afe-a5ed-41e80b7975f9","order":66,"text":"Authorization to obtain medical information: The Requestor authorizes the Employer to contact the health-care provider identified above solely for the limited purpose of confirming the disability and the need for the requested accommodation. This authorization may be revoked in writing at any time and does not extend to any unrelated medical information.","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"16","cflou":false,"active":true,"displayConditions":[{"field":"bac14276-01e0-4ec8-8709-8aa7c75c94d4","value":"1","type":"add","operator":"="}]},{"id":"dfeafbca-d845-42f6-9fa6-4d481e71b130","order":67,"text":"Executed at [City, State], on [Date signed].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"24","cflou":false,"active":true},{"id":"2d594b6c-52f8-4f5d-ac60-bcdb5da13868","order":68,"text":"THE REQUESTING INDIVIDUAL","fontSize":"12","textAlign":"left","bold":true,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"6fb8f663-261b-4519-8f24-b079fff2b175","order":69,"text":"Name: [Full Legal Name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"26a1ee23-dd47-4099-a34e-44d534c76cf4","order":70,"text":"Signature: ______________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"b8546f02-dc47-41dd-abce-64e7461bc3da","order":71,"text":"FOR THE EMPLOYER","fontSize":"12","textAlign":"left","bold":true,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"678e004c-d857-41d5-bdb6-53ab0de815fc","order":72,"text":"Organization: [Employer / Company Name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"6b81e28c-68cc-4c8b-a2bd-b20784cfacd4","order":73,"text":"Name: [Authorized signatory — Name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"4a9fdc7c-2546-4464-a2e0-e2a896ab402b","order":74,"text":"Title: [Authorized signatory — Title]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"b66d996a-ecc3-4c51-8bdb-3ab84a0b4e81","order":75,"text":"Signature: ______________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"f4fbc910-980b-41ff-a205-eb4fe2138d51","order":76,"text":"ADA / Accommodation Contact","fontSize":"12","textAlign":"left","bold":true,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"0f2054c0-f2c8-4e03-932e-bb1ad8c00fdb","order":77,"text":"[Contact Name], [Contact Title]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"ad279ef8-05aa-4dee-b026-0ac7b69d2578","order":78,"text":"Email: [Contact Email] | Phone: [Contact Phone]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"62d6be12-5323-488c-a06e-191d92c50b70","order":79,"text":"[Street Address], [City, State, ZIP]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true}]