ADA Reasonable Accommodation Request

ADA Title I reasonable accommodation request form. Initiates the interactive process between employee and employer per EEOC enforcement guidance.

Employee Information

• Employee name
• Employee ID
  Optional if your organization uses employee IDs for routing.
• Work email
• Department
• Manager name

Accommodation Request

• What are you requesting?
• Describe the accommodation you are requesting
  Explain what adjustment would help you perform the essential functions of your job.
• What workplace barrier or limitation is this request meant to address?
  Describe the work-related difficulty without sharing more medical detail than necessary.
• Which essential job functions are affected?
  Select all that apply.
• Is this request temporary or ongoing?

Supporting Information

• Are you submitting supporting documentation?
• Upload supporting documentation
  Optional. Upload only documents relevant to the accommodation request.
• Additional context
  Optional. Share any other information that would help HR understand the request.

Consent and Review

• I understand this form may include PII or medical information and will be handled confidentially to the extent required by law.
• I consent to HR contacting me to discuss this request and participate in the interactive process.
• Employee signature
• Submission date