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:

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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