Instructions: Employee/applicant shall contact the treating health care provider to complete this form. Employee/
applicant should return the completed form to ADA coordinator at Humboldt State University Human Resources. If
you have any questions, please contact Nancy Resnick, ADA Coordinator, at 707.826.3626, or confidential fax 707.826.3625. A
carbon copy, photocopy, or facsimile copy of this true medical release shall be as valid as an original of same. For
telecommunications needs, please use the California Relay Service at 877.735.2929 TTY.