Campus Assistive Device/Auxiliary Assistance Request Form

Equity & Diversity

EQUITY & DIVERSITY

PHONE: (818) 677-2077

FAX: (818) 677-4802

LOCATION: UN 285

Assistive Device/Auxiliary Assistance
Request Form

Part I - Disability Information:

1. Name:		2. Department:	3. Work Phone:
4. Job Title:		5. Working Job Title:
	Faculty: Staff: Management Personnel Plan (MPP): Temporary: (Indicate end date of appointment and if position is sligible for renewal)
6. Disabling condition(s):

7. Is the disabling condition permanent? Yes: No:
8. What are the essential job functions for which reasonable accomodation is being requested?

9. Has the disability been verified? Yes: No:
	If this is a first-time application, please indicate in what form (e.g., statement from medical doctor, health practitioner, rehabilitation professional). If this is not a first-time application, please state that verification was submitted with the original request.

10. Form Completed By:

Signature: ___________________________________

Date: __________

Part II - Request for Auxiliary Assistance:

1. Describe the functions for which assistance is being requested, e.g., reading/note-taking, interpreting, driving, etc.

2. Enter the hourly rate / hours per week / number of weeks per year:

	Hourly Rate: $
	Hours per week:
	Weeks per year:

3. Amount requested from Auxiliary Assistance Program:
	Auxiliary Assistance Program:$
	Departmental/Unit contribution: $

Part III - Request for Equipment:

1. Specify the equipment vendor and cost in as much detail as possible. Please list all components and prices separately. Alternative documentation should be attached to this form.

2. Describe how the equipment will be utilized:

3. Amount requested from Auxiliary Assistance Program:
	Auxiliary Assistance Program:$
	Departmental/Unit contribution: $

Revised 8/03