Nycha Employment Application – Fill Out and Use This PDF

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The New York City Housing Authority (NYCHA) will make reasonable accommodations for qualified job applicants and employees with disabilities to enable them to perform the essential functions of their jobs, or to enjoy the equal benefits and privileges of employment and the employment process, unless providing such an accommodation would be unduly costly, extensive, substantial or disruptive, or would fundamentally alter the nature of operation of the Housing Authority or any of its programs. This form shall be made available to, and used by, all job applicants and employees requesting a reasonable accommodation in accordance with NYCHA’s

Reasonable Accommodation Policy and Procedure for Employees and Job Applicants.

INSTRUCTIONS: Where necessary or requested, NYCHA supervisory staff, the Human Resources Placement and Certification Coordinator (Interviewer), and/or the Employee Reasonable Accommodation Coordinator (ERAC) shall assist applicants or employees in completing this form.

Job applicants - Complete Sections I and II and submit this form to the staff supervising the application process. Current NYCHA employees - Complete Sections I and III and submit this form to your immediate supervisor. Interviewers/Supervisors - Complete Section IV, and return one copy of the completed form to the job applicant or employee requesting the accommodation. In a separate confidential file, retain a copy of completed form, and send a copy to the ERAC (Human Resources Department, 90 Church Street, 5th Floor, New York, NY 10007). The original form is to be sent to the decision-maker. (In the case of the Supervisor, it will be the Department Director, not the HR Director.)

Department Director/HR Director - Complete Section V, as appropriate.

Section I

Both job applicants and current employees should complete this section.

Name

Address

Phone

Accommodation Requested (attach additional sheets and any supporting medical documentation, as appropriate)

Section II

To be completed by job applicants only.

Position/title applied for gvbhfghgfh

Department/Development (if known)

Job Vacancy Notice Number (if known)

Date of Examination/Interview

Over

NYCHA 015.208 (Rev. 9/04) - Reverse

Section III

To be completed by NYCHA employees only (even if you are currently on leave).

Position/Title

Department/Development

Supervisor

Section IV

This section should be completed by the Interviewer of the job applicant, or by the supervisor of the em- ployee requesting a reasonable accommodation.

Name and Title

Department/Development

Phone

Date Request Received

Signature

Section V

In the event a reasonable accommodation is granted at the outset of the process, this section should also be completed before sending a copy to the ERAC.

If the request involves a personnel action that requires the Human Resources Director’s approval, describe the recommended reasonable accommodation and check RECOMMENDED.

Disposition of the Request for Reasonable Accommodation:

If a reasonable accommodation has been GRANTED/RECOMMENDED, describe the accommodation:

Name and Title

Department

An employee may file a written appeal of the Department Director’s decision with the ERAC

within 10 days of receipt of the decision.