The Personnel Board of Jefferson County is an equal opportunity employer and does
not unlawfully discriminate on the basis of race, sex, religion, age, national origin,
veteran status, or disability. This form is used to submit requests for accommodation
in the testing process for qualified individuals with disabilities. This document
must be completed, either by the applicant or by the ADA Ombudsman, in order for
a request for accommodation to be considered. If you need assistance in completing
this form, please contact the ADA Ombudsman at 279-3582 or 279-3595. Every
request for accommodation will receive individual consideration on its own facts
Nature of Disability:
Please describe your specific disability in enough detail to enable the
ADA Ombudsman to determine whether you have a qualifying disability, whether an
accommodation is necessary, and if so, what accommodations are appropriate. Please
include specific information about how your disability impairs the performance of
the activities that will be part of the testing process.
Please specify the accommodation that you believe would be reasonable and
would effectively accommodate your disability. If there are other possible alternative
accommodations, please list them as well.
By submitting this form you certify that all of the information provided
on this form is true. Under PBJC Rules 9.5(c), 9.14, and 12.1, any material misrepresentation
on this form could result in your disqualification from the competitive testing
process, and/or disciplinary action.