How to Complete the Request for Review (Campus Accommodation and/or Medical Separation) Form

Instructions: How to Complete the Request for Review (Campus Accommodation and/or Medical Separation) Form

** Please read the below instructions before filling out the Request for Review (Campus Accommodation and/or Medical Separation) form (Word). The below instructions are also available in a printable format (PDF).


The Request for Review (Campus Accommodation and/or Medical Separation) form is used when the department has exhausted efforts to reasonably accommodate an employee's work restrictions in their current position or in another position within the department.

The department should first exhaust all efforts to reasonably accommodate the employee's work restriction(s). If these efforts are unsuccessful, the department should submit a Request for Review to the Campus Leave Management Committee. The committee will determine if the employee's restrictions can be reasonably accommodated in another position on campus, or if a 90-day transfer search is required or if medical separation is appropriate.

These instructions will assist you in completing the Request for Review (Campus Accommodation and/or Medical Separation) form.


Before the department can complete the review form, the following information relative to the employee's current work restrictions should be gathered:

  • All relevant correspondence to and from the employee
  • All correspondence to and from the employee's Health Care Provider
  • Dates of Absence
  • All leave dates
  • Medical documentation (if any)
  • Activity Tracking Log for the Interactive Process ad Reasonable Accommodation (if used)


Type or print the information requested in the first row of boxes:

  • Employee's name
  • Employee's Job Title
  • Employee's Title Code
  • Employee's Department name

Sample Entry

Step 1

Protected Leave

Protected leaves, also referred to as Family Medical Leave (FML), consist of the Family and Medical Leave Act (FMLA), California Family Rights Act (CFRA) and Pregnancy Disability Leave (PDL).

Click on the links to find out more about these protected leaves:

FMLA/CFRA – the employee is not eligible if the employee does not have one year of service (it does not have to be consecutive) and 1250 hours actually worked in the 12 months preceding the need for leave. PDL does not have eligibility requirements, other than being pregnant; therefore, all pregnant employees are eligible.

Scenario 1 and a sample entry

  • The employee has a serious medical condition an¬d cannot perform one or more of their essential job functions. The employee meets the eligibility requirements for FMLA/CFRA (1 year of service and 1250 actual hours worked in the past 12 months). The employee has been out on FML from 2/1/12 – 4/30/2012.

Step 2

Supplemental Family and Medical Leave (For Personnel Polices for Staff Members (PPSM) employees only)

Supplemental Family and Medical Leave is an entitlement for PPSM employee's whose need for a family and medical leave that is in progress continues beyond 12 work weeks.

In this case, a regular status employee shall be entitled to supplemental leave for up to 12 work weeks or until the end of the leave year, whichever is less.

Learn more about Supplemental Family and Medical Leave.

Scenario 2A and a sample entry

  • The employee is represented by a collective bargaining agreement and not eligible for Supplemental Leave.

Scenario 2B and a sample entry

  • PPSM employee has a serious health condition and cannot perform the essential job functions. The employee is out on a medical leave for 12 work weeks from 2/1/11 – 4/30/11. The health care provider submits additional medical documentation that the employee's serious health condition continues and the employee will need to be off work through 7/24/11. The employee is placed on Supplemental Leave from 5/1/11 – 7/24/11.

Step 3

Workers' Compensation

Workers' Compensation is a state-mandated insurance plan designed to provide benefits and assistance to employees who are injured as a result of their employment or who develop a work-related illness.

Disability Management Services coordinates this benefit for the campus.

Workers' Compensation cases submitted for medical review must be discussed with Disability Management Services (DMS).

Scenario 3 and a sample entry

  • There are no pending workers' compensation claims.

Step 4

Current Work Restrictions and Duration

Work restrictions and duration of those restrictions are provided by the employee's health care provider. Once received, review the documents from the health care provider and enter the most recent work restrictions and the duration of those restrictions in the box. Attach the documentation to the form.

Scenario 4 and a sample entry

  • The employee provides you with a letter from their health care provider with restrictions that prevent the employee from performing the essential functions of the job for three months (6/11/11 – 9/1/11). You receive a second health care provider letter extending the duration of the restrictions for six more months (9/1/11 - 3/1/12). Attach copies of both health care provider letter to the review form and file the letters in the employee's medical file.

Step 5

Essential Job Functions

The essential functions of a position should already be noted on the job description. If they are not, consider the following:

  • The fundamental job duties of the position.
  • The position exists to perform this function.
  • There would be serious consequence if this function was not performed.

Learn more about Essential Job Functions.

Scenario 5 and a sample entry

Step 6

Interactive Process

The interactive process is a good faith on-going communication process between the supervisor (or appropriate designee) and employee to identify potential reasonable accommodation(s) for work restrictions that will allow the employee to perform the essential functions of the job. Disability laws require that employers and employees engage in the Interactive Process.

Learn more about interactive process and department obligations.

Scenario 6 and a sample entry

  • On 1/5/11, the supervisor met with the employee to discuss work restrictions and possible accommodations that would allow the employee to return to work. The supervisor spoke with the employee again on 1/15/11 regarding possible accommodations.

Step 7

Describe all Reasonable Accommodations

A reasonable accommodation is a modification or an adjustment to a job or the work environment that will enable the employee or qualified applicant with a disability to perform the essential job functions. Accommodations can include physical alterations to the work environment, shift changes, leave of absence, and many others.

In this step, it is important that you document all accommodations offered, provided, considered, and those requested by the employee but not provided. Provide a narrative with details and dates and outcomes where appropriate.

Learn more in Policies and the Guide to Managing Human Resources.

Scenario 7 and a sample entry

Step 8

Employee Notification

Employees must be notified, in writing, prior to requesting the review of campus accommodation or medical separation.

Step 9

Summarize the Reasons

Briefly summarize (be specific) the reasons why the department is requesting this review.

Scenario 9 and a sample entry