WPC{  kM!dlDV!`&h1d lCB}m@Skb¯T2F"4k< S*Z7k7)кM`SgF4]oYp$|.ZF rV3.؅FpW{oRkX2ԋ'sn8tpߟ͉|k|Hr/!m9+"_}0(YB16WA'#.z,^!S:!aqa k| x_RQQC2k\ ^wʅe@-ꨖܺrEjǠpk'~s;W}nٴζW~=( l14֣n3Sʞ -pbŜf =v2m3d#PP-?26|`"AL+>3;f,t`ϧ h%hlyjǼH%L~P߂\mt/< ^ԾB[uY#UN % 0(w 4 3 B J EL NN ^ P m\ qs 0D B( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( B*E B*o o o o o o o o o o o o o o o o o o o o o B7 B* B B BG4 HP2300 PS0(hH  Z 6Times New Roman RegularX($.sL33|xq3L U g )  _T"T"G(#_9/99_(3$ !   d&p d Pd&p Pd d3+0 d d d&P d d d dCTriple 1+| d d d !  _*,X,` XX*@ -XX NorthDakotaStateUniversity   @  #X`,X-u#DocumentationtoSupportaRequest    @] ] forReasonableAccommodationontheBasisofDisability&f%XX`,   #X`,X%&f# Employee:   1.Completethetopportionofthisform. t  2.Attachacopyofyourcurrentpositiondescription `  3.Arrangetohavetheremainderofthisformcompletedbyanappropriatehealthcareor L  rehabilitationprofessional. 8  4.Submitthecompletedformtothe_NDSU_ԀOfficeofHumanResourcesorhavetheprofessional $ t  providingtheinformationsubmitit. `     EmployeeName_______________________________________________________ 8    Positionat_NDSU_Ԁ_____________________________________________________ $   AX ) xd3E|xA    Tothehealthcareorrehabilitationprofessionalprovidingthisinformation : c PleasecompletebothsidesofthisformasfullyaspossibleinordertoassistUniversity S personnelinrespondingtothisemployee'srequestforanappropriateandreasonable ? accommodationbasedondisability.Attachadditionalinformation,ifnecessary. + &f%XX`,1.Identifythisemployee'sdisability(ordisabilities)andindicatethedateofthecurrentdiagnostic  evaluation,thedateoftheoriginaldiagnosis,andanydiagnosticcriteriaand/ortestsused.  2.Describethefunctionalimpactofthedisabilityordisabilitiesintermsoftheemployee'scurrent "#" position(positiondescriptionshouldbeattached). ## @( OVER  .)0  {/*1 _3.Identifythetreatments,medications,assistivedevices/servicescurrentlyprescribedorinuse.  4.Describetheexpectedprogressionorstabilityoftheimpactofthedisabilityovertime.   5.Provideabriefdescriptionoftherelevantprofessionalcredentials(medicalspecialization,licensure, P etc.)ofthehealthcareorrehabilitationprofessionalprovidingthisinformation. (x #X`,X%&f#&f%XX`,_______________________________________________________________ H'") #X`,X%&fV #XX`,Healthcareorrehabilitationprofessionalprovidingthisinformation(PLEASEPRINT).#X`,X #&f%XX`,  (p#* #X`,X%&f #XX`,_________________________________________________________________((;(#Date___________ *%- Signatureofhealthcareorrehabilitationprofessionalprovidingthisinformation.#X`,X #&f%XX`, D+&. #X`,X%&f #