IASHEP’S COMMITMENT TO ADA AND ADAAA COMPLIANCE REQUEST FORM

It is the policy of International Association of Safety, Health and Environmental Professionals (IASHEP) to comply with the Americans with Disabilities Act (ADA) and the Americans with Disabilities Act Amendments Act (ADAAA). Candidates for certification shall not suffer discrimination for having a disability as described in the ADA or ADAAA. NAME: DATE: WORK PHONE: HOME PHONE: EMAIL: NATURE OF THE QUALIFYING DISABILITY: (Please describe the nature, extent, and duration of your disability.) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 2 REQUESED/SUGGESTED ACCOMMODATION: (Please describe the accommodations you believe are needed to enable you to perform the essential functions of this membership or completing an IASHEP approved course or test. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ PHYSICIAN CONTACT INFORMATION (Please provide name, address, telephone and fax numbers. The physician may receive a letter/fax from us requesting information on your impairment/disability and recommendations for accommodations.) Physician Contact: —————— ————————————————————————- Physician Address: ______________________________________________________ Physician Phone Number: ________________________________________________ Physician Fax Number: ___________________________________________________ 3 I authorize the release of necessary and potential confidential medical information regarding my disability as deemed necessary by the International Association of Safety, Health and Environmental (IASHEP). I also attest to the fact that a copy of this document has been given to me for review and reference. Signature: ____________________________________________________ Date: _________________________________ [To signatory: In non-physician review cases, decisions regarding accommodations will be made within 10 days of the receipt of this form by IASHEP. Due to delays that may be caused in communications with physicians, no specific decision date can be provided for physician review cases.]