Michigan Civil Service Commission




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CS-1669

REV 8/2007


Michigan Civil Service Commission


400 South Pine Street, P.O. Box 30002

Lansing, Michigan 48909



AUTHORITY: Article 11, §5, Michigan Constitution of 1963, Civil Service Commission Rule 1-8, and Civil Service Regulation 1.04.

Response to Disability Accommodation Request


This form must be completed after an employee has filed a Disability Accommodation Request Form. The departmental Accommodation Coordinator (or other designated official) must complete Part A and send a copy to the requesting employee. (Civil Service Regulation 1.04 requires the Accommodation Coordinator to issue a written response within eight weeks after receiving a completed Disability Accommodation Request Form from an employee.)
PART A: ACCOMMODATION COORDINATOR’S RESPONSE TO REQUEST FOR ACCOMMODATION

  1. Accommodation Coordinator’s Name

     

  1. Coordinator’s Title

     

  1. Department/Agency

     

  1. Date Request Received

     

  1. Employee’s Name

     

  1. Employee’s Identification Number

     

  1. Final Disposition of Request (Check one box and then describe or explain in detail.)

     Employee’s Request APPROVED (Describe the disability and the final, approved accommodation[s].)

     Employee’s Request DENIED (Explain the reason[s] for denying the requested accommodation[s].)

     

    Accommodation Coordinator’s Signature

    Date

     

PART B: EMPLOYEE’S acknowledgment (When completed, return to Accommodation Coordinator.)

    I acknowledge receipt of this answer and I

 AGREE

 DISAGREE (If you disagree, please explain and attach any necessary documentation.)

     

    Employee’s Signature

    Date



Response to Disability Accommodation Request


INSTRUCTIONS FOR COMPLETING THE FORM

PART A: To be completed by the departmental Accommodation Coordinator or designee.

Questions

Instructions


Questions 1-6

Self-explanatory.

Question 7

Describe your final decision on the employee’s written request for an accommodation:




A. If you APPROVE an accommodation, check the box for “Employee’s Request APPROVED” and describe in detail the following:




  1. The employee’s disability.

  2. The accommodation approved.

  3. How the approved accommodation addresses the functional limitations and essential job functions.




B. If you DENY the employee’s request for an accommodation, check the box for “Employee’s Request DENIED” and describe in detail your reason(s) for denying the request.

After completing Part A, the Accommodation Coordinator or designee sends a copy of the completed form to the employee.

PART B: To be completed by the employee.

Instructions


The employee should review Part A and indicate agreement or disagreement with the final decision. If the employee disagrees with the final decision, the employee may provide an explanation and any necessary documentation to substantiate disagreement.

Upon completion of Part B, the employee keeps a copy and returns the signed copy of the Response to Disability Accommodation Request (and attached documentation, if applicable) to the departmental Accommodation Coordinator or designee.

NOTICE TO EMPLOYEE: Appeal of accommodation decision.


If an employee is dissatisfied with the final response of the Accommodation Coordinator or the Accommodation Coordinator fails to issue a final response within eight weeks, the employee may appeal through the appropriate grievance procedure or take other action authorized by law.


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