ADA Accommodation Request Form

Collects employee requests for workplace accommodations under ADA, including disability-related needs, essential job functions, requested accommodations, and review details.

Employee Information

• Employee name
• Employee ID
• Work email
• Department
• Job title
• Manager name

Accommodation Request

• Date of request
• Type of accommodation requested
• Describe the workplace barrier or limitation
  Explain what task, environment, policy, or communication barrier is affecting your ability to perform your job.
• Essential job functions affected
  Select the essential functions impacted by the barrier.
• Requested accommodation details
  Describe the specific accommodation(s) you are requesting and how they would help.
• Is this request time-sensitive?

Medical or Supporting Information

• Do you have supporting medical documentation available?
• Upload supporting documentation
  Upload only if requested by HR or if you choose to provide documentation now.
• May HR contact your healthcare provider for clarification if needed?
• Additional supporting information
  Optional. Include any information that helps explain the need for accommodation.

Interactive Process Preferences

• Preferred contact method
• Do you need any communication support for meetings or follow-up?
• Alternative accommodations you would consider
  Optional. Share other reasonable options that would also address the barrier.
• Availability for an interactive process meeting

Employee Certification

• I consent to HR processing this request for the purpose of evaluating a workplace accommodation.
• I understand that information provided will be handled confidentially and shared only on a need-to-know basis.
• I certify that the information provided is true and complete to the best of my knowledge.
• Employee signature
• Submission date

HR Review Details

• Reviewer name
• Review date
• Review status
• Approved accommodation
• Implementation notes
• Follow-up date