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DHR Form EO 16B <br />(July 2018) <br />CONFIDENTIAL <br />Reasonable Accommodation Checklist <br />To Be Used by Decision Maker <br />Check all that apply <br />1. The Reasonable Accommodation procedure was initiated by <br />o job applicant request; <br />o employee request; <br />o employee or job applicant representative request; <br />o employee's medical professional; <br />o employee's supervisor; <br />0 other: (specify) <br />2. The job applicant or employee has <br />o an impairment that substantially limits a major life activity, <br />o an impairment that does not substantially limit a major life activity. <br />If the job applicant or employee does not have an impairment that <br />substantially limits a major life activity, whether chronically or episodically, <br />there is no duty to provide a reasonable accommodation and the rest of this <br />checklist need not be completed. <br />JOB APPLICATION PROCESS <br />3. If the Reasonable Accommodation Request pertained to the Job <br />Application Process, the job applicant requested an accommodation for <br />(check all that apply and continue to #4 and #5) <br />o the job application process; <br />o examination; <br />o performance test; <br />o interview; <br />0 other: <br />(specify) <br />4. The individual (or representative) who made the request completed and <br />submitted DHR Form EO 010 Reasonable Accommodation Request Form <br />for Job Application Process to the decision maker: <br />Yes No <br />