University of Nebraska Kearney

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    Primary Contact Person John Lakey, Director Human Resources 1000 Founders Hall (308) 865-8426 The University of Nebraska at Kearney is committed to providing any reasonable accommodations necessary to allow an individual with a disability to effectively and safely

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    For Information - Contact:
    Learning Strategies Office
    Memorial Student Affairs Building 172
    (308) 865-8214

     

    The goal at the University of Nebraska at Kearney is to develop an academic community accessible to all individuals while encouraging the skills necessary for independence and self-sufficiency. Therefore, it is the responsibility of the student at UNK to identify themselves as an individual with a disability and to provide documentation/verification by a qualified individual. Admitted students with disabilities are encouraged to schedule an appointment with the Learning Strategies Office (308)865-8214 to learn about campus and program accommodations and services available to them.
    See Learning Strategies Office website for further information.

     

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    Primary Contact Person Cheryl Bressington, ADA Coordinator Office of Affirmative Action 1203 Founders Hall (308) 865-8655 The University of Nebraska at Kearney is committed to providing any reasonable accommodations necessary to allow an individual with a

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    HEALTH CARE PROFESSIONAL STATEMENT ON EMPLOYEE ACCOMMODATION REQUEST University of Nebraska at Kearney John Lakey, Human Resources Director (308) 865-8426 (Complete form onscreen, print, sign and submit to UNK Human Resources) Employee Name: Physician/Psychologist: I. Diagnosis

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    University of Nebraska at Kearney (Complete form onscreen, print, sign and submit to UNK Human Resources) Name Telephone Address City Zip Status: Student Staff Faculty Other (Please explain) Accommodation(s) Requested: (Press Enter/Return at end of each

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    Role of the University of Nebraska at Kearney Criteria for University Responsibility The University of Nebraska at Kearney is committed to providing any reasonable accommodations necessary to allow an individual with a disability to effectively and safely function in the campus environment. In order to

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    ADA COMMITTEE/CONTACTS The University of Nebraska at Kearney's Americans with Disabilities Act (ADA) Committee exists as a vehicle to advise the Chancellor on ADA policies and practices. The Committee has two distinct charges. First, the Committee is charged with reviewing and supporting the development of

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    University of Nebraska at Kearney The University of Nebraska at Kearney has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794) or Section 202 of the

Health Care Professional Statement on Employee Accommodation Request


University of Nebraska at Kearney

John Lakey, Human Resources Director
(308) 865-8426
(Complete form onscreen, print, sign and submit to UNK Human Resources)

 

 

Employee Name:

Physician/Psychologist:


I. Diagnosis Information:
If the diagnosis is psychiatric, please include DSM-IV classification:
(Press Enter/Return at end of each line)


Medical/Psychiatric tests conducted that support diagnosis:
(Press Enter/Return at end of each line)



If diagnosis is learning disability, please include breakdown of scores from tests:
(Press Enter/Return at end of each line)



Current medication that could require accommodation for side effects:
(Press Enter/Return at end of each line)



II. Determination of Disabling Condition:

In your medical judgement is the patient substantially limited in a major life activity because of an impairment at the present time? Yes No
If yes, what is the major life activity?

 

Walking Performing Manual Tasks
Speaking Concentrating
Breathing Lifting
Hearing Working
Seeing Learning
Interacting with Others Thinking
Other (describe)

Please discuss how the patient is limited in the major life activity identified above. If the major life activity is 'working' identify some jobs that he/she could not perform because of the impairment.*
(Press Enter/Return at end of each line)




III. Determination of Impact on Job Functions
(To be completed by Human Resources)
(Press Enter/Return at end of each line)




Essential job functions as presently performed. Please indicate if patient is able to perform each of these job functions (Y); cannot perform the job function (N); or requires accommodation (A).
(Press Enter/Return at end of each line)



Thank you for providing us with the benefit of your expertise. Please sign and date this form and return it with the appropriate medical documentation to John Lakey, Director, Human Resources, University of Nebraska at Kearney, Kearney, NE 68849.


_________________________________________________
Physician/Psychologist Signature and Date

*This information is requested to determine whether there is a class of jobs or a broad range of jobs the individual cannot perform to be used in the determination of substantially limited in this category.