ADA Accommodation Request Form

Form for employees to request workplace accommodations under the ADA, document disability-related needs, identify essential job functions affected, and support review of the accommodation process.

Employee Information

• Employee Name
• Employee ID
• Work Email
• Department
• Job Title
• Manager Name

Accommodation Request

• Request Date
• Work-Related Limitation or Barrier
  Describe the job task, workplace condition, or barrier that is affected by your disability-related need.
• Essential Job Functions Affected
  Select the essential job functions that are impacted. Choose all that apply.
• Requested Accommodation
  Describe the accommodation(s) you believe would help you perform the essential functions of your job.
• Expected Duration
• Date Accommodation Is Needed By

Supporting Information

• Are you providing supporting documentation?
• Type of Supporting Documentation
• Upload Supporting Documents
• Additional Notes
  Use this field for any other information relevant to the request.

Interactive Process Preferences

• Preferred Contact Method
• Preferred Phone Number
• Meeting Accessibility Needs
  For example: captioning, ASL interpretation, accessible location, or other communication support.
• Alternative Contact Person
  Optional. Provide only if you want someone else to help coordinate communication.

Employee Certification

• I certify that the information provided is true and complete to the best of my knowledge.
• I consent to HR or the designated accommodation coordinator reviewing this information for the purpose of evaluating my accommodation request.
• I understand this information will be treated as confidential and shared only with those who need it to evaluate or implement the accommodation.

HR Review Details

• Review Status
• Review Notes
• Follow-Up Required
• Next Review Date