Request for accommodation

My Patient_______________________________________has Chemical Sensitivity. The Americans with Disabilities Act (and Rehabilitation Act of 1973) requires employers to "reasonably accommodate" disabilities "unless undue hardship would result", and prohibits discrimination in hiring, advancement, compensation or training. The items checked below will accommodate this handicapping condition and are medically necessary to reduce significant illness caused by trace exposures to petrochemicals and combustion products in my patient:

• _______Avoid petrochemical pesticides and use less toxic pest control. Consult the National Coalition Against the Misuse of Pesticides (Washington, D.C.) or Common Sense Pest Control by Olkowski, or Albert Green, entomologist, 202-708-6948.
• _______ Eliminate petrochemical "air fresheners" in the building.
• _______Avoid all petrochemical cleaning agents, waxes, etc. Also avoid irritants and chlorine containing products. Consult Nontoxic and Natural by Dr. Dadd, Less Toxic Living by Carolyn Gorman, Nigra Enterprises (818-889-6877, discount supplier), etc.
• _______In repairs and remodeling, avoid petrochemical products. Safer substitutes are available: eg., Nigra, books above. This includes adhesives (including carpet backing), sealants, roofing, paints, solvents, coated fabrics etc. Double ventilation flow after any petrochemical use, up to one year for remodeling.
• _______Provide activated charcoal filter device in the patient's work area with adequate capacity to remove remaining petrochemicals, and regular filter replacements.
• _______Provide parking arrangement that avoids parking garage and walking past many cars on parking lot.
• _______Educate co-workers in patient's area that petrochemicals in personal and cosmetic products can cause illness.
• _______Allow the patient to leave the building promptly in event of an illness reaction. Provide alternative work space, even at home if needed, during unavoidable building problems.
• _______Use a no-smoking policy as passive smoke aggravates illness.

• _______Other____________________________________________________________
• __________________________________________________________________________
• __________________________________________________________________________

Please feel free to call me for any questions. Please submit a written accommodation plan to me within 30 days. Thank you.

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