Request for Reasonable Accommodation

1
To ensure equality of access for individuals with disabilities, the Government of the Virgin Islands (GVI) will provide reasonable accommodation(s) to enable employees to perform the essential functions of their jobs and to participate in all GVI programs and activities.

Individuals applying for positions can request a reasonable accommodation in connection with the application process. Applicants shall direct their requests for accommodation to their employing agency.

Employees shall initiate requests for any desired disability-related workplace accommodation by completing this form or contacting Human Resources. This form will be emailed to Human Resources.

The GVI will take such requests seriously. This policy applies to exempt and non-exempt employees. If you have any questions, please contact your Human Resources office or Division of Personnel's Strategy and Organizational Development team at training@dop.vi.gov or 340-774-8588.
2
Employment Type* This field is required.Is this request for an applicant or employee?
EmployeeApplicant
3
Name* This field is required.
First Name
Middle Initial
Last Name
Suffix
4
Employee Number* This field is required.If an applicant, please enter 0 below.
5
Department/Agency* This field is required.If an applicant, please enter the hiring department or agency.
Agriculture
Board of Education
Career and Technical Education Board
Casino Control Commission
Collective Bargaining
Corrections Bureau
Economic Development Authority
Economic Research
Education (Department of)
Election System
Energy Office
Finance
Fire Service
Government Employees' Retirement System
Governor's Office
Health
Housing Authority
Housing Finance Authority
Human Services
Information Technology
Inspector General - V.I.
Internal Revenue
Juan Luis Hospital
Judicial Branch
Justice
Labor
Law Enforcement Planning Commission
Legislature
Licensing and Consumer Affairs
Lieutenant Governor's Office
Lottery
Magens Bay Authority
Management and Budget
Motor Vehicles
National Guard
Personnel
Planning and Natural Resources
Police Department
Port Authority
Property and Procurement
Public Broadcasting System
Public Defender - Territorial
Public Employees Relations Board
Public Finance Authority
Public Services Commission
Public Works
Schneider Regional Medical Center
Sports, Parks & Recreation
Taxicab Commission
Tourism
University of the Virgin Islands
Veterans Affairs
viNGN
VITEMA
Waste Management Authority
Water and Power Authority
West Indian Company
6
District* This field is required.
St. Croix
St. Thomas/St. John
7
Position Title* This field is required.If an applicant, please enter the position title for which you have applied.
8
Email* This field is required.Please enter the email address where information can be sent about this request.
example@example.com
9
Human Resources Email* This field is required.
example@example.com
10
Phone Number* This field is required.Please enter a phone number where we can contact the employee or applicant.
Area Code
Phone Number
11
Responsibilities* This field is required.What are your employment responsibilities? (Describe briefly.)
Huge
Large
Normal
Small
Ok
Ok
12
Disability* This field is required.What is the disability for which you are requesting an accommodation?
13
Job Impact* This field is required.What job duties and responsibilities are impacted by your disability?
Huge
Large
Normal
Small
Ok
Ok
14
Accommodation* This field is required.What specific disability accommodation are you requesting? (Be as specific as possible, e.g. adaptive equipment, reader, interpreter and indicate if the request is permanent or temporary)
Huge
Large
Normal
Small
Ok
Ok
15
Alternate Accommodation* This field is required.What alternative accommodation(s) would be responsive to your request? (Be as specific as possible, e.g. adaptive equipment, reader, interpreter and indicate if the request is permanent or temporary)
Huge
Large
Normal
Small
Ok
Ok
16
Time Sensitive* This field is required.Is the accommodation time sensitive? Please state yes or no. If yes, please also explain:
17
Documentation* This field is required.Do you have medical documentation to support the need for a disability? In most cases, we will need to obtain medical documentation regarding your disability. In some cases it will be necessary to discuss the nature of the disability with your physician to address your request for an accommodation. If deemed necessary, HR can request an independent medical evaluation of your disability.
YESNO
18
Documentation UploadPlease upload your medical documentation.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Request* This field is required.Have you previously requested a disability accommodation through HR?
YESNO
20
History* This field is required.Have you previously requested a disability accommodation through HR?
No
Yes, for the same disability
Yes, for a different disability
21
Signature* This field is required.Acknowledgement of Request for Accommodation I am requesting an accommodation under the Americans with Disabilities Act. I agree to fully cooperate with HR in responding to my request. I understand that, in most cases, I may need to provide medical documentation regarding my disability to assist in determining a reasonable accommodation. I agree that I will provide the requested medical documentation in a timely manner. I also understand that, in some cases, discussion(s) of my disability with my physician may be necessary to address my request for an accommodation. In addition, if deemed necessary, HR can request an independent medical evaluation of my disability to arrange for a reasonable disability accommodation.
Clear
Should be Empty: