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2. Request for Reasonable Accommodation
   Many accommodations are simple changes in procedures or one-on-one assistance to ensure that access is provided; curbside assistance, alternative format for communication, printing information in large font, etc. This form may be completed and returned directly to the Department providing the program or service so they may best serve you. The form may also be completed and returned to:
   St. Charles County Human Resources
   ADA Coordinator
   201 N. 2nd
   Room 519
   St. Charles, MO 63301
   For assistance in completing this form contact Human Resources, ADA Coordinator, at 636-949-7320, or email.
4. Name
6. Phone
7. Date
9. Address1
11. City
12. State
13. Zip
15. 1. Choose the box which applies to you.

    1. Applicant
    2. Citizen

    1. Employee
17. 2. Reason for the Application

    1. Assistance with performing essential job functions.
    2. Assistance with testing and hiring procedures.
    3. Assistance with using or accessing services and programs provided by the county.
    4. Accessibility of facilities or buildings.
19. 3a. Title of Position
    (Applied for or Performing)
21. 3b. Identify the Program or Service
23. 3c. Identify the Building or Facility
25. 4. Department with Position or Service:
27. 5. Describe your disability and based on your disability the assistance needed for Question 2.
29. 5a. If you are requesting a very specific accommodation, how will that accommodation assist you?
31. 5b. If you do not know what accommodation is needed do you have any suggestions as to what options we should explore? If yes, explain.
33. 5c. Is your accommodation request time sensitive? If yes, explain.
35. 5d. Have you had an accommodation in the past for your limitation?

    1. No

    1. Yes*
36. *If yes, what was it and how effective was it?
38. 6. Any additional information that you believe would be helpful for the county in processing this request for accommodation.
40. Signature

    1. Applicant's Signature

    Checking this box serves as a signature.
42. Employees Only
44. 7. What specific job function, if any, are you having difficulty performing?
46. 8. What specific employment benefit, if any, are you having difficulty accessing?
48. 9. What limitation is interfering with you ability to perform your job or access employment benefits?
50. Signature

    1. Employee Signature

    Checking this box serves as a signature.
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field