REQUEST FOR REASONABLE ACCOMMODATION

Please complete this form in its entirety and keep a copy for yourself.
To assist the Accommodation Review Committee (ARC) in evaluating your request, you must submit relevant
current medical documentation that is necessary to support your request for a reasonable accommodation. All
medical information and documentation will be kept confidential. See Administrative Procedure 1017 for further
information. NOTE: YOU ARE RESPONSIBLE FOR ANY EXPENSE INCURRED IN PROVIDING MEDICAL
DOCUMENTATION TO THE ARC.

Questions? Need help with your request? Contact the ARC Helpline at 312-681-2225, option 6, FAX: 312-275-8722
or ARC@transitchicago.com.

PLEASE PRINT OR TYPE - USE EXTRA SHEETS IF NECESSARY

Send this form and any supporting documentation, including a resume or explanation of your skills and experience
attaching additional pages as necessary, to: Chicago Transit Authority, ARC c/o Human Resources, FAX:
312-275-8722, EMAIL: ARC@transitchicago.com or MAIL: 567W.LakeStreet.3rdFloor.Chicago.IL 60661-
1465. You will be contacted by a representative of the ARC when your request is received. The ARC will use your
home address on file with the CTA to contact you.

Name: _ Badge #:, _

Home Address: _

Phone Number: _ Email Address: _

Position: _

Name of Current Manager/Supervisor: _

Work Location: _ Work Phone Number: _

What is the medical condition for which you are requesting a reasonable accommodation? _

Describe what part of your job you cannot do because of your medical condition: _

Describe the accommodation you are requesting: _

Describe how this accommodation would help you: _

Provide any other information that will help the ARC reach its decision:, _

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AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION

Please complete and return this authorization with your Request for Reasonable Accommodation Form. This release
will be submitted to your doctor(s) in the event that additional information is needed regarding the medical condition(s)
for which you are requesting a reasonable accommodation.

Section A: Individual for whom medical records are requested.

Full Name (Please print): _ CTA Badge #: _

Street Address: City/State/Zip: _

Phone: _ Date of Birth: _

Section B: Person or organization from which medical records are requested.

!Address:

Phone: _ Fax: _

Section C: Purpose of Disclosure.

Iro evaluate the individual's request for a reasonable accommodation in the workplace, because of a substantial
medical restriction and/or disability.
~ection D: Information to be Disclosed

• I hereby authorize Chicago Transit Authority or its agent to contact Dr. (s) to request
and obtain all medical information related to the current health condition(s) for which I am requesting a reasonable
accommodation.
~ I UNDERSTAND THE FOLLOWING PROVISIONS:
• I understand I have the right to refuse to complete this Authorization to Disclose Medical Information form. If I refuse to
consent to this disclosure of information, the CTA Accommodation Review Committee may not
be able to determine my eligibility and/or requirements for a reasonable accommodation, but will still attempt to process
my application for a reasonable accommodation..
• I have the right to inspect and receive copies of my medical information that are disclosed to the CTA
Accommodation Review Committee.
• I have the right to revoke this consent at any time. The revocation must be in writing and signed by me and
must be submitted to the Records Department of the person/organization named in Section B. Revoking
this consent will have no effect on disclosures made before the revocation of consent.
• The CTA Accommodation Review Committee will keep the medical information disclosed pursuant to this
authorization confidential, disclosing it only on a need-to-know basis.
• By checking the box or boxes below, I am authorizing the release of the following information that
is relevant to the Accommodation Review Committee's consideration of my request for a
reasonable accommodation:
o HN/AIDS (as defined by Illinois statute) - will not be released unless specifically indicated.
o Alcohol/s ubs tance abuse and/or tre a tment- will not be released unless specifically indicated.
o Developmental disa bilitie s- will not be released unless specifically indicated.
OMental health - will not be released unless specifically indicated.

Section E: Authorization
Unless an earlier date is specified, this authorization will expire 12 months from date of signature below.

Signature of Individual: Date (Month/DayNear): ,-_

Signature Date

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To be completed by the physician treating you for the condition(s) related to this request for an accommodation:

PHYSICIAN'S STATEMENT
Your patient has requested that the Chicago Transit Authority (CTA) provide a reasonable accommodation so that your patient can perform
the essential functions of the job your patient is currently performing or is seeking. Please return this completed form to your patient.

Please attach additional sheets as necessary to respond to the following:

1. State the patient's diagnosis.

2. State the patient's prognosis for each diagnosis provided.

3. Identify the activity(ies) that are limited by the patient's physical/mental impairment(s).

4. Describe how and to what extent the patient's medical condition limits the activity(ies) identified in your response to number 3
above. Please be as specific as possible. For example, if the patient's ability to lift is limited, please state how much the patient
can lift and how many times per day the patient can lift. This information is necessary to determine an appropriate accommodation.

5. Describe how the restriction(s) limit any of this patient's ability to perform the patient's essential job functions. Essential job
functions are the main duties of the job.

6. Indicate the projected duration of each limitation.

Health Care Provider's Signature Date

Print Name Type of Practice

Address City/ State Zip Code

Phone No. Fax No.

Physician License No.

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REQUEST FOR REASONABLE ACCOMMODATION CHECKLIST

Have you?

../ Read Administrative Protocol 1017, Reasonable Accommodations in the

Workplace for Employees with Substantial Medical Restrictions and-or
Disabilities

../ Completed Form 702 .05

../ Completed the Authorization to Disclose Medical Information if you would like the
Accommodation Review Committee to be able to speak directly with your
medical professional

../ Attached current medical documentation supporting your request, including your
diagnosis(es) and the expected duration of your restrictions related to your
medical condition(s)

../ Attached a current resume

../ Provided a completed Physician's Statement

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