CINXE.COM
Office of Institutional Equity and Accessibility Accommodation Request Form*
<!doctype html> <html class="no-js" lang="en"> <head> <meta charset="iso-8859-1"> <meta http-equiv="x-ua-compatible" content="ie=edge"> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <link rel="apple-touch-icon-precomposed" sizes="152x152" href="images/apple-touch-icon-152x152-precomposed.png"> <link rel="apple-touch-icon-precomposed" sizes="144x144" href="images/apple-touch-icon-144x144-precomposed.png"> <link rel="apple-touch-icon-precomposed" sizes="120x120" href="images/apple-touch-icon-120x120-precomposed.png"> <link rel="apple-touch-icon-precomposed" sizes="114x114" href="images/apple-touch-icon-114x114-precomposed.png"> <link rel="apple-touch-icon-precomposed" sizes="76x76" href="images/apple-touch-icon-76x76-precomposed.png"> <link rel="apple-touch-icon-precomposed" sizes="72x72" href="images/apple-touch-icon-72x72-precomposed.png"> <link rel="apple-touch-icon-precomposed" href="images/apple-touch-icon-precomposed.png"> <title>Office of Institutional Equity and Accessibility Accommodation Request Form*</title> <meta http-equiv="content-type" content="text/html; charset=iso-8859-1"> <meta name="robots" content="noindex"> <link rel="stylesheet" type="text/css" href="publicside_assets/jquery_filer/css/jquery.filer.css"> <link rel="stylesheet" type="text/css" href="publicside_assets/jquery_filer/css/themes/jquery.filer-dragdropbox-theme.css"> <script src="https://use.typekit.net/feb7wgs.js"></script> <script>try{Typekit.load({ async: true });}catch(e){}</script> <link rel="stylesheet" href="publicside_assets/bower_components/reportingform_app.css"> <style type="text/css"> body { background-color: #00356b; } .sectionheader { color: #FFF; background: #00356b; } </style> </head> <body> <div id="wrapper" class="row"> <!--big wrap--> <div class="small-12 columns"> <!-- big wrap--> <header> <div class="row" id="reportheader"> <div id="reportheader-left"> <p><img src="https://maxfs-useast-01.s3.amazonaws.com/yale/logos/YaleUniv.gif?response-cache-control=must-revalidate%2C%20post-check%3D0%2C%20pre-check%3D0&response-content-disposition=inline%3B%20filename%3D%22YaleUniv.gif%22&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAV47ECHXWF5MDWZZG%2F20241218%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20241218T044604Z&X-Amz-SignedHeaders=host&X-Amz-Expires=7200&X-Amz-Signature=b36df4c5aee0dee84ab75dc286d3a984837fc0bd05b4a949de6bd310a25f7c5c" alt="Yale University Logo"></p> </div> <div id="reportheader-right"> <h1>Office of Institutional Equity and Accessibility Accommodation Request Form*</h1><br> </div> </div> <div id="main_instructions" class="row"> <div class="large-12 columns"> <p><span style="color: #3366ff; font-size: 18pt;"><strong>* For Staff Accommodation Requests please complete the <a href="https://yalesurvey.ca1.qualtrics.com/jfe/form/SV_9yOscUwWIQXUx14"><span style="color: #3366ff;">HR Staff Accommodation Form</span></a>. Staff Accommodations are addressed by the <a href="https://your.yale.edu/work-yale/benefits/absence-management-and-accommodations-services/staff-accommodations-program"><span style="color: #3366ff;">Yale Human Resources Staff Accommodations Program</span></a>.</strong></span></p> <p> </p> <p>The Office of Institutional Equity and Accessibility (OIEA) administers Yale University’s Accommodation Program for faculty, psychiatry residents, postdoctoral and postgraduate associates and fellowss, and interns with disabilities. Yale provides reasonable accommodations to those with documented disabilities and applicants for employment at Yale who seek accommodations in the job application process due to a disability.<br /> <br /> This form will not be placed in your employment record file. The content of this request is confidential.<br /> <br /> If this request is related to a work-related injury or illness, you should contact <a href="https://your.yale.edu/work-yale/benefits/leaves-absence/workers-compensation" target="_blank">Yale’s Workers’ Compensation</a> office to request an accommodation.<br /> <br /> Please have your Health Care Provider or Specialist complete the <a href="../reportingform.php?YaleUniv&layout_id=9" target="_blank">Health Care Provider/Specialist form</a>; <strong>delayed submission of this form will prevent the prompt processing of your request.</strong> If you already have a Doctor's or Specialist's note, please upload it below.</p> <p> </p> <p><span style="font-size: 10pt;"><em><span style="color: #0a0a0a; font-family: Proxima-nova, sans-serif;">The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic information," as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or any individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.</span></em></span> </p> </div> </div> </header> <main> <form name="IR" id="IR" enctype="multipart/form-data" accept-charset="iso-8859-1" method="post" action="" data-abide novalidate> <input type="hidden" name="institution" id="institution" value="YaleUniv"> <input type="hidden" name="layout_id" value="8"> <input type="hidden" name="x_requestor_ip" value="8.222.208.146"> <input type="hidden" name="x_requestor_starttime" value="1734497164.2554"> <input type="hidden" name="x_requestor_token" value="74d0d2113130e84d2aa7e592aab7e1fd"> <input type="hidden" name="recaptcha_response" id="recaptcha_response"> <div data-abide-error class="alert callout" style="display: none;"> <p id="error_detail_top"></p> </div> <section> <h2 class="sectionheader">Entering your email address ensures that you receive a copy of this form.</h2> <div id="section1"> <div class="column row"> <div class="sectioninstructions"></div> </div> <div class="row"> <div class="generallabel"> </div> <div class="generalinput"> <a href="https://cm.maxient.com/reportingform.php?YaleUniv&layout_id=8&promptforauth=true">Enable additional features by logging in.</a> </div> </div> <div class="row" style="display: none;"> <div class="generallabel"> <label for="reporters_full_name">Your full name:</label> </div> <div class="generalinput"> <input type="text" name="reporters_full_name" id="reporters_full_name" maxlength="80" value=""> </div> </div> <div class="row" style="display: none;"> <div class="generallabel"> <label for="reporters_title">Your position/title:</label> </div> <div class="generalinput"> <input type="text" name="reporters_title" id="reporters_title" maxlength="80" value=""> </div> </div> <div class="row" style="display: none;"> <div class="generallabel"> <label for="reporters_phone_number">Your phone number:</label> </div> <div class="smallerinput"> <input type="text" name="reporters_phone_number" id="reporters_phone_number" maxlength="20" value=""> </div> </div> <div class="row" > <div class="generallabel"> <label for="reporters_email_address">Your email address:</label> </div> <div class="generalinput"> <input type="email" name="reporters_email_address" id="reporters_email_address" maxlength="80" value=""> <span class="form-error">Email address must be of a valid format.</span> </div> </div> <div class="row" style="display: none;"> <div class="generallabel" > <label for="reporters_physical_address">Campus Address:</label> </div> <div class="generalinput"> <input type="text" name="reporters_physical_address" id="reporters_physical_address" maxlength="80" value=""> </div> </div> <div class="row"> <div class="generalinput"> <input type="hidden" name="nature" id="nature" value="HIDE"> </div> </div> <div class="row"> <div class="generalinput"> <input type="hidden" name="urgency" id="urgency" value="HIDE"> </div> </div> <div class="row"> <div class="smallerinput"> <input type="hidden" name="date_of_incident" id="date_of_incident" value="2024-12-17"> </div> </div> <div class="row" style="display: none;"> <div class="generallabel"> <label for="time_of_incident" id="lbl_time_of_incident">Time of incident:</label> </div> <div class="smallerinput"> <input autocomplete="off" type="text" name="time_of_incident" id="time_of_incident" aria-labelledby="lbl_time_of_incident" maxlength="10" value=""> </div> </div> <div class="row"> <div class="generalinput"> <input type="hidden" name="location_of_incident" id="location_of_incident" value="hide"> </div> </div> <div class="row" style="display: none;"> <div class="generallabel"> <label for="location_of_incident_specific">Net ID:</label> </div> <div class="generalinput"> <input autocomplete="off" type="text" name="location_of_incident_specific" id="location_of_incident_specific" size="40" maxlength="100" value="" style="position:relative;"> </div> </div> </div> </section> <section> <h2 class="sectionheader">Background Information</h2> <div id="section3"> <div class="column row"> <div class="sectioninstructions"></div> </div> <div id="involvedPersons"> <div class="personrow clonedInput" id="personrow0"> <fieldset> <legend class="show-for-sr legend_person">Involved party 1</legend> <div class="row small-up-1 medium-up-2 large-up-4"> <div class="column"> <label for="person_0" class="label_person">Your Full Name </label> <input autocomplete="off" type="text" name="person[]" id="person_0" class="input_person" maxlength="50" value=""> </div> <div class="column"> <label for="dob_0" class="label_dob">Position/ Title</label> <input autocomplete="off" type="text" name="dob[]" id="dob_0" class="input_dob" maxlength="10" value=""> </div> <div class="column"> <label for="phone_0" class="label_phone">Phone Number</label> <input autocomplete="off" type="text" name="phone[]" id="phone_0" class="input_phone" maxlength="50" value=""> </div> <div class="column"> <label for="email_0" class="label_email">Pronouns (optional)</label> <input autocomplete="off" type="email" name="email[]" id="email_0" maxlength="50" class="input_email" value="" data-lpignore data-1p-ignore> </div> <div class="column" > <label for="halladdress_0" class="label_halladdress">Net ID #</label> <input autocomplete="off" type="text" name="halladdress[]" id="halladdress_0" maxlength="50" class="input_halladdress" value="" data-lpignore data-1p-ignore> </div> </div> </fieldset> </div> </div> </div> </section> <section> <h2 class="sectionheader">Questions</h2> <div id="addquest"> <div class="sectioninstructions"><p>Help us to learn more about you and your accommodation request.</p></div> <input type="hidden" name="numberOfAdditionalQuestions" value="16"> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[1][answer]">OIEA facilitates accommodation requests for individuals whose relationship with the university falls within the list provided below; please select the category that best fits your relationship with the university. If you are a staff member seeking an accommodation, please complete Human Resources' online intake form available at: https://your.yale.edu/work-yale/benefits/absence-management-and-accommodations-services/staff-accommodations-program.<span class="required">(Required)</span></label> <select autocomplete="off" name="aq[1][answer]" id="aq[1][answer]" class="answers" required> <option value="" disabled selected hidden>Please Choose...</option> <option value="Faculty">Faculty</option> <option value=" Postdoctoral or postgraduate associate or fellow"> Postdoctoral or postgraduate associate or fellow</option> <option value=" Psychiatry Resident"> Psychiatry Resident</option> <option value=" Research Affiliate"> Research Affiliate</option> <option value=" Intern"> Intern</option> <option value=" Campus Visitor"> Campus Visitor</option> <option value=" Alumni"> Alumni</option> <option value=" Job Applicant"> Job Applicant</option> </select> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[2][answer]">Please share your specific diagnosis(es).<span class="required">(Required)</span></label> <input autocomplete="off" type="text" name="aq[2][answer]" id="aq[2][answer]" class="answers" required maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[3][answer]">Please provide a brief explanation of the accommodation(s) you are seeking.<span class="required">(Required)</span></label> <textarea autocomplete="off" spellcheck="true" name="aq[3][answer]" id="aq[3][answer]" class="answers" required rows="5"></textarea> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <fieldset> <legend class="addquest_label">Have you worked with an OIEA staff member on this or a related accommodation request in the past?<span class="required">(Required)</span></legend> <div class="answers radio-group"> <label class="label_radiocheck"> <input autocomplete="off" type="radio" name="aq[4][answer]" value="Yes" required>Yes </label> <label class="label_radiocheck"> <input autocomplete="off" type="radio" name="aq[4][answer]" value="No" required>No </label> </div> <span class="form-error addquest_error">This field is required.</span> </fieldset> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[5][answer]">If so, please share the staff member's name below.</label> <input autocomplete="off" type="text" name="aq[5][answer]" id="aq[5][answer]" class="answers" maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <fieldset class="checkbox-group" data-validator-min="1"> <legend class="addquest_label">Are you currently on an approved leave (continuous or reduced work schedule or intermittent)? Check all that apply.<span class="required">(Required)</span></legend> <div class="answers"> <label class="label_radiocheck"> <input autocomplete="off" type="checkbox" name="aq[6][answer][]" value="Yes" required data-validator="checkbox_limit">Yes </label> <label class="label_radiocheck"> <input autocomplete="off" type="checkbox" name="aq[6][answer][]" value="No" required data-validator="checkbox_limit">No </label> <label class="label_radiocheck"> <input autocomplete="off" type="checkbox" name="aq[6][answer][]" value="Continuous Leave" required data-validator="checkbox_limit">Continuous Leave </label> <label class="label_radiocheck"> <input autocomplete="off" type="checkbox" name="aq[6][answer][]" value="Reduced Schedule" required data-validator="checkbox_limit">Reduced Schedule </label> <label class="label_radiocheck"> <input autocomplete="off" type="checkbox" name="aq[6][answer][]" value="Intermittent Leave" required data-validator="checkbox_limit">Intermittent Leave </label> </div> <span class="form-error addquest_error">You must make at least one selection.</span> </fieldset> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[7][answer]">Please share your current home address.<span class="required">(Required)</span></label> <input autocomplete="off" type="text" name="aq[7][answer]" id="aq[7][answer]" class="answers" required maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[8][answer]">Please share your current work address.<span class="required">(Required)</span></label> <input autocomplete="off" type="text" name="aq[8][answer]" id="aq[8][answer]" class="answers" required maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[9][answer]">Dean's or Supervisor's Name<span class="required">(Required)</span></label> <input autocomplete="off" type="text" name="aq[9][answer]" id="aq[9][answer]" class="answers" required maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[10][answer]">Health Care Provider's or Specialist's Name<span class="required">(Required)</span></label> <input autocomplete="off" type="text" name="aq[10][answer]" id="aq[10][answer]" class="answers" required maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[11][answer]">Health Care Provider's or Specialist's Phone Number<span class="required">(Required)</span></label> <input autocomplete="off" type="text" name="aq[11][answer]" id="aq[11][answer]" class="answers" required maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[12][answer]">Health Care Provider's or Specialist's Email Address</label> <input autocomplete="off" type="text" name="aq[12][answer]" id="aq[12][answer]" class="answers" maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[13][answer]">By typing your name below, you authorize the Health Care Provider/Specialist named above (or their designee) to communicate with a representative from Yale's Office of Institutional Equity and Accessibility (OIEA) about matters related to your accommodation request and authorize the release of personal health information, as it relates to your accommodation request, via the Health Care Provider/Specialist form.<span class="required">(Required)</span></label> <input autocomplete="off" type="text" name="aq[13][answer]" id="aq[13][answer]" class="answers" required maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[14][answer]">Please provide your date of birth. This information will only be used to identify you when OIEA contacts your health care provider/specialist.<span class="required">(Required)</span></label> <div class="row"> <div class="medium-3 columns"> <input autocomplete="off" type="date" name="aq[14][answer]" id="aq[14][answer]" class="answers" value="" required pattern="(?:19|20)[0-9]{2}-(?:(?:0[1-9]|1[0-2])-(?:0[1-9]|1[0-9]|2[0-9])|(?:(?!02)(?:0[1-9]|1[0-2])-(?:30))|(?:(?:0[13578]|1[02])-31))" maxlength="10"> <span class="form-error addquest_error">This field is required.</span> </div> </div> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[15][answer]">Please provide your Net ID<span class="required">(Required)</span></label> <input autocomplete="off" type="text" name="aq[15][answer]" id="aq[15][answer]" class="answers" required maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> <div class="row"> <div class="small-12 columns question"> <label class="addquest_label" for="aq[16][answer]">If you are requesting a Parking Accommodation and hold a State of Connecticut handicapped permit, please share the number below:</label> <input autocomplete="off" type="text" name="aq[16][answer]" id="aq[16][answer]" class="answers" maxlength="100"> <span class="form-error addquest_error">This field is required.</span> </div> </div> </div> </section> <section> <h2 class="sectionheader">Supporting Documentation</h2> <div id="supportdocs"> <div class="column row"> <div class="sectioninstructions" id="uploadFilesInstructions"> <p> <b><p>Please have your Health Care Provider or Specialist complete the <a href="https://cm.maxient.com/reportingform.php?YaleUniv&layout_id=9" target="_blank">Health Care Provider/Specialist form</a> ; delayed submission of this form will prevent the prompt processing of your request.<p></b> If you have a note from your health care provider or specialist that specifies your medical condition and lists any medication(s) used to treat that medical condition, please upload it below.<p> Your Health Care Provider/Specialist may require a signed authorization for use or disclosure of protected health information before sharing information with OIEA. Yale Health has an Authorization for Use or Disclosure of Protected Health Information form that can be used for this purpose. You may access that form <a href="https://hipaa.yale.edu/sites/default/files/files/5031-FR.pdf" target="_blank">here</a>.<p> 5GB maximum total size.<br><strong>Attachments require time to upload, so please be patient after submitting this form.</strong> </p> </div> </div> <div class="column row"> <input tabindex="-1" type="file" name="uploadedFiles[]" id="filer_input" aria-labelledby="uploadFilesInstructions" multiple="multiple"> </div> </div> </section> <section> <div class="row"> <div class="small-12 columns text-center" id="submit_btn"> <h2 class="show-for-sr sectionheader">Submission</h2> <p><input autocomplete="off" type="checkbox" id="sendCopyToAuthor" name="sendCopyToAuthor" value="Yes" CHECKED READONLY><label for="sendCopyToAuthor">Email me a copy of this report</label></p> <input autocomplete="off" class="large button" type="submit" name="submit" id="submit" value="Submit"> </div> </div> </section> <div class="row"> <div class="small-12 columns"> <div data-abide-error class="alert callout" style="display: none;"> <p id="error_detail_bottom"></p> </div> </div> </div> </form> </main> </div><!-- big wrap column--> </div><!-- big wrap --> <script src="publicside_assets/bower_components/jquery/dist/jquery.js"></script> <script src="publicside_assets/bower_components/what-input/what-input.js"></script> <script src="publicside_assets/bower_components/foundation-sites/dist/foundation.min.js"></script> <script src="publicside_assets/bower_components/app.js"></script> <script src="https://cdn.jsdelivr.net/npm/timepicker@1.11.14/jquery.timepicker.min.js"></script> <script src="publicside_assets/cloneform/clone-form-td2.js"></script> <script src="publicside_assets/jquery_filer/js/jquery.filer.AHmods102620.min.js"></script> <script src="https://use.fontawesome.com/b22e7499d6.js"></script> <script type="text/javascript"> // add tabindex="0" and link icon from Font Awesome to help visually identify as a link any <a> elements, and so tabbing will work correctly on form var alinks = document.getElementsByTagName('a'); for (i=0; i<alinks.length; i++) { alinks[i].setAttribute("tabindex","0"); alinks[i].innerHTML += " <i class='fa fa-external-link' aria-hidden='true'></i>"; } function ShowHide(elementId) { var element = document.getElementById(elementId); if(element.style.display != "block") element.style.display = "block"; else element.style.display = "none"; } function ShowPersonRow(elementId) { var element = document.getElementById(elementId); element.style.display = ""; // using table-row here breaks IE6/7 } function ShowLinkRow(elementId) { var element = document.getElementById(elementId); element.style.display = ""; // using table-row here breaks IE6/7 } function HideLinkRow(elementId) { var element = document.getElementById(elementId); element.style.display = "none"; } $('#time_of_incident').timepicker({ 'scrollDefault': 'now', 'step': '15', 'timeFormat': 'g:i A' }); // jquery_filer for file uploads $('#filer_input').filer({ limit: 30, maxSize: 5000, changeInput: true, showThumbs: true, addMore: true, captions: { button: "Choose Files", feedback: "Choose files to upload", feedback2: "file(s) selected", drop: "Drop file here to upload", removeConfirmation: "Are you sure you want to remove this file?", errors: { filesLimit: "Only {{fi-limit}} files are allowed to be uploaded.", filesType: "This type of file cannot be uploaded.", filesSize: "{{fi-name}} is too large. 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Please review the highlighted fields.'; document.getElementById('error_detail_bottom').innerHTML = '<i class="fa fa-exclamation-triangle fa-2" aria-hidden="true"></i> ' + visibleErrors.length + ' fields have errors. Please review the highlighted fields.'; $('html, body').animate({ scrollTop: $(invalid_fields[0]).offset().top - 40 }, 1000, function() { $(invalid_fields[0]).focus(); /*for putting focus on the first invalid field*/ }); }); // 11/18/19: HTML5 input type=date detection var isDateSupported = function () { var input = document.createElement('input'); var value = 'a'; input.setAttribute('type', 'date'); input.setAttribute('value', value); return (input.value !== value); }; if (isDateSupported()) { $('#lbl_date_of_incident').append('<span class="show-for-sr">Format is MM/DD/YYYY.</span>'); } if (!isDateSupported()) { $('#lbl_date_of_incident').append('<br>Format is YYYY-MM-DD.'); } </script> </body> </html>