Accommodation Case File Template

Case file form for documenting an ADA accommodation request, the interactive process, supporting information, decision, and follow-up actions.

Case Overview

• Case title
  Short title for the accommodation case file.
• Case owner
  HR representative, accommodation coordinator, or manager responsible for the case file.
• Submission date
  Date this case file entry is created.
• Request type
• Case status
• Confidentiality acknowledgment
  Confirm that this case file may contain sensitive PII and should be handled on a need-to-know basis.

Employee and Role Information

• Employee name
  Employee name for case tracking.
• Employee ID
  Optional internal identifier if your organization uses one.
• Department
  Department or business unit.
• Job title
  Current job title.
• Work location
  Primary worksite, team location, or remote status.
• Essential job functions affected
  Describe the essential job functions impacted by the barrier or limitation.

Accommodation Request Details

• Request summary
  Brief summary of the accommodation requested.
• Barrier or limitation
  Describe the workplace barrier, limitation, or access issue prompting the request.
• Requested accommodation type
  Select all accommodation categories that apply.
• Requested accommodation details
  Additional details about the specific accommodation requested.
• Urgency level
  Use only if needed for prioritization.

Supporting Information and Consent

• Supporting information received
  Indicate whether supporting information has been provided.
• Type of supporting information
  Select the types of supporting information in the case file.
• Medical information needed
  Check only if medical or health-related information is necessary to evaluate the request.
• Consent to review supporting information
  Consent for HR or the designated reviewer to review submitted supporting information for accommodation evaluation.
• Anonymous submission requested
  Use only if your process allows anonymous intake for preliminary concerns; accommodation case files typically require identity for follow-up.

Interactive Process Documentation

• Interactive process started
• Initial contact date
  Date the employee or representative first contacted the organization about the request.
• Meeting notes
  Document discussions, questions asked, responses, and agreed next steps.
• Alternative accommodations considered
  List alternatives discussed during the interactive process.
• Interim measures
  Temporary measures implemented while the request is under review.
• Next review date
  Date for the next check-in or follow-up.

Decision and Implementation

• Decision
• Decision date
  Date the decision was made.
• Decision rationale
  Document the basis for the decision, including any limitations, alternatives considered, and business justification if applicable.
• Implementation owner
  Person or team responsible for implementing the approved accommodation.
• Implementation date
  Date the accommodation was implemented or is expected to be implemented.
• Follow-up required
  Check if the accommodation needs a follow-up review after implementation.

Employee Review and Acknowledgment

• Employee acknowledgment
  I understand this case file documents the accommodation process and may be used to support HR review and follow-up.
• Additional comments
  Optional final comments or clarifications.
• Submitter name
  Name of the person submitting this case file entry, if different from the employee.