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Run: Accommodation Case File Template

Accommodation Case File Template for documenting an ADA request, the interactive process, supporting information, the decision, and follow-up actions in one ...

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Case Overview

Case title (required)

Short title for the accommodation case file.

Case owner (required)

HR representative, accommodation coordinator, or manager responsible for the case file.

Submission date (required)

Date this case file entry is created.

Request type (required)

Case status (required)

Confidentiality acknowledgment (required)

Confirm that this case file may contain sensitive PII and should be handled on a need-to-know basis.

Yes No N/A

Employee and Role Information

Employee name (required)

Employee name for case tracking.

Employee ID

Optional internal identifier if your organization uses one.

Department (required)

Department or business unit.

Job title (required)

Current job title.

Work location

Primary worksite, team location, or remote status.

Essential job functions affected (required)

Describe the essential job functions impacted by the barrier or limitation.

Accommodation Request Details

Request summary (required)

Brief summary of the accommodation requested.

Barrier or limitation (required)

Describe the workplace barrier, limitation, or access issue prompting the request.

Requested accommodation type (required)

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 (required)

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.

Yes No N/A

Consent to review supporting information (required)

Consent for HR or the designated reviewer to review submitted supporting information for accommodation evaluation.

Yes No N/A

Anonymous submission requested

Use only if your process allows anonymous intake for preliminary concerns; accommodation case files typically require identity for follow-up.

Yes No N/A

Interactive Process Documentation

Interactive process started (required)

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 (required)

Decision date (required)

Date the decision was made.

Decision rationale (required)

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.

Yes No N/A

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.

Yes No N/A

Additional comments

Optional final comments or clarifications.

Submitter name

Name of the person submitting this case file entry, if different from the employee.

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