Request for Accommodation
Associate Information
CarMax is committed to providing applicants and associates with a disability with equal opportunities to the benefits and privileges of employment. To meet this commitment and requirement, CarMax provides reasonable accommodations to qualified individuals with disabilities.
The process of identifying whether, and to what extent, a reasonable accommodation is required involves an interactive process among the individual requesting an accommodation, management, human resources, and, often, healthcare professionals. No specific form of accommodation is guaranteed. Rather, an accommodation should be tailored to meet the needs of the individual, while being effective and not causing undue hardship to the business or an undue threat to safety. This requires a cooperative and flexible approach that promotes a prompt and equitable resolution of requests for accommodation.
Please answer all questions completely and sign the authorization
(You may be asked for further information from your health care provider at a later point)
Forms may be submitted confidentially by placing the completed form in a sealed envelope
marked confidential and providing the envelope to your manager or HR Representative
Questions? Contact the ADA Administrator at 1-888-910-1293 or ADA_Committee@carmax.com
Click Here For The Religious Request for Accommodation Form
Describe Impairment
Describe how your impairment
- Affects your ability to perform the essential functions of your job, and/or
- Prevents you from accessing the work environment, and/or
- Prevents you from accessing a benefit/privilege of employment.
Identify each specific job function, accessibility issue and/or benefit/privilege affected by your condition.
Be specific about how the impairment limits you in each instance. If necessary, ask your manager for a copy
of your job description to review the essential functions of your job.
| Describe Job Duty, Accessibility Issue, Benefit and/or Privilege and How the Impairment Limits you at Work
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Health Care Provider
Can you provide documentation from a health care professional regarding your impairment, functional limitations and your need for accommodation(s)?
| Can you provide documentation?
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| If yes, please enter your Health Care Provider name. If no, please explain.
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Leave and/or additional breaks as an Accommodation.
The Family and Medical Leave Act (FMLA) entitles eligible employees of covered employers to take unpaid, jobprotected leave for specified family and medical reasons. In general, to be eligible an employee must have
worked for an employer for at least 12 months, meet the hours of service requirement in the 12 months
preceding the leave, and work at a site with at least 50 employees within 75 miles. A copy of your Notice of
Eligibility and Rights and Responsibilities can be found online here.
For associate’s electing to use FMLA to address his/her leave needs please contact AbsenceOne at 1-855-253-9101 or visit online here AbsenceOne
| Are you requesting a leave as an Accommodation?
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| You will be able to request specific leave requests below.
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Authorization
ASSOCIATE AUTHORIZATION
I authorize any licensed physician, or other certified medical provider to release to CarMax or its third-party administrator Sedgwick, medical information pertinent to evaluating my request for a job accommodation. I
also authorize my medical providers, CarMax representatives, Sedgwick and other administrators to share and discuss my
medical information with each other for the purposes of evaluating a potential accommodation. I hereby acknowledge that
I have the right to receive a copy of the medical information provided to CarMax or Sedgwick.
I understand that by submitting my request for accommodation that an ADA Team member will engage me in the interactive process via my preferred contact method regarding my request. I understand that an ADA Team member will only discuss limitations/impairments/needed accommodations as a result of my chronic medical condition and not my chronic medical condition itself-at no point will I need to disclose my chronic medical condition and I understand I am encouraged to not disclose my condition
| Do you authorize as described above?
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| The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or
requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we
are asking that you and your physicians not provide any genetic information when responding to any request for medical information, such as in the
Healthcare Certification response from a physician. ‘Genetic information," as defined by GINA, includes an individual’s family medical history, the results
of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member
receiving assistive reproductive service
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Requested Accommodation(s) or Leaves
Enter your first request. Some fields are dependent on others and will be grayed out if not required, otherwise fill all fields out. Click Save Case Item when you have completed your first request. You may then enter additional requests and save each one. You'll see all of your requests in a table below to review before you click submit.
Describe each request in detail. For intermittent leaves and additional breaks be specific in what dates, times and frequency you are requesting.
