Town of Brookfield Fire Department

645 Janacek Road Brookfield, WI 53045 (262) 796-3792 Fax: (262) 796-0410

AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE FORM TO BE COMPLETED BY DISABLED INDIVIDUALS

In Accordance with State and Federal laws, the Town of Brookfield is committed to ensure non-discrimination in employment of qualified individuals with disability. If you have a condition which qualifies as a physical or mental disability under ADA, you are invited to volunteer the following information which will be treated confidentially and only used for affirmative action purposes. Your refusal to provide information will not jeopardize or adversely affect any consideration you may receive for employment. Under the Rehabilitation Act of 1973, Americans with Disabilities Act, or its State Law counterparts a handicapped or disabled individual is one who: has a physical or mental impairment which substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment. "Major life activities" means the functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working. DUE TO PHYSICAL OR MENTAL DISABILITY: Please indicate if you need test accommodations due to reasons other than a handicap or disability, such as illiteracy or English being your second language. YES / NO Please describe type of accommodations needed (such as someone to read the examination to you). The above completed information is true to the best of my knowledge. Signature: ____________________________________ Date: ______/______/_______ I prefer not to fill out this form and/or its does not apply. Signature: ____________________________________ Date: ______/______/_______ The provision for test accommodations may be granted by the Town Administrator's Office after review and evaluation on a case by case basis. Factors considered will include the nature of the examination and the knowledge, skills and abilities required for the job. RETURN TO EMPLOYMENT PAGE RETURN TO HOME PAGE