I understand that the forgoing records and medical information are limited only to that
information which the University needs to know to evaluate my reasonable accommodation
request. Accordingly, the University is attempting to obtain the medical information related to
the following, as applicable: (1) confirmation that my medical condition is a disability under the
Americans with Disabilities Acts as amended; (2) the functional limitations(s) or work related
restrictions associated with the stated disability; (3) why the requested reasonable
accommodation is needed; (4) clarification of medical information previously submitted to the
University; and/or (5) recommendations regarding alternative accommodations.
I understand that the information that is collected and discussed is to be treated with
confidentiality. However, directly relevant information may be shared with
supervisors/managers, others who need to know how to address work restrictions and/or
accommodations, or those responsible for emergency treatment in order to make decisions or
provide advice on matters relating to my request for reasonable accommodation.
This Release terminates 90 days after the date of the signature below.