ADA Accommodation Request Form
An ADA Accommodation Request Form for documenting an employee’s limitation, the essential job functions affected, and the accommodation being requested. Use it to start the interactive process with clear fields, consent, and HR review tracking.
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Overview
This ADA Accommodation Request Form template captures the information HR needs to start and document the interactive process: employee details, the limitation being experienced, the essential job functions affected, the accommodation requested, supporting documentation, and follow-up review fields. It is built for employee self-service or HR intake, with room for preferred contact method, accessibility needs for meetings, and a confidentiality acknowledgment.
Use this template when an employee needs a workplace adjustment tied to a disability or medical limitation and you want a consistent intake path instead of scattered email requests. It is especially useful when requests may involve multiple reviewers, time-limited accommodations, or documentation that must be tracked without exposing unnecessary PII. The HR review section helps you record status, notes, follow-up requirements, and the next review date so the request does not stall.
Do not use this form as a medical questionnaire or a place to collect broad health history. If your process does not require supporting documentation, make that field optional and keep the form short. If the request is anonymous, this template is not the right fit because accommodation requests usually require a known employee identity and a way to coordinate the interactive process. The best version of this form uses progressive disclosure, clear required versus optional fields, and a submission confirmation that explains what happens next.
Standards & compliance context
- Collect only the PII and medical-related details needed to evaluate the accommodation request, consistent with GDPR data minimization and the minimum-necessary principle.
- If the form is public-facing or employee self-service, it should meet WCAG 2.1 AA accessibility expectations, including labels, focus order, and readable validation messages.
- Use the confidentiality acknowledgment and HR review fields to support controlled handling of sensitive accommodation information and an auditable review trail.
- Do not use this form to gather unrelated medical history or diagnosis details when a functional limitation and job impact are sufficient for review.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Employee Information
This section identifies the employee and routes the request to the right HR owner without collecting unnecessary personal details.
- Employee Name
- Employee ID
- Work Email
- Department
- Job Title
- Manager Name
Accommodation Request
This is the core of the form, where the employee explains the limitation, the job functions affected, and the specific accommodation being requested.
- 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
This section lets HR capture whether documentation exists and where it is stored without forcing sensitive details into free text.
- 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
This section helps HR contact the employee in an accessible way and reduces friction during follow-up conversations.
- 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
This section confirms the employee understands the request is accurate, reviewed, and handled confidentially.
- 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
This section creates the audit trail for status, notes, follow-up, and the next review date so the request does not get lost.
- Review Status
- Review Notes
- Follow-Up Required
- Next Review Date
How to use this template
- 1. Configure the employee and request fields so the form collects only the minimum information needed to identify the employee, understand the limitation, and route the request.
- 2. Add conditional logic to show supporting documentation, meeting accessibility needs, or alternate contact fields only when they are relevant to the employee’s situation.
- 3. Assign HR or an accommodation specialist as the reviewer and define the review status options so each submission moves through the same workflow.
- 4. Submit the form after the employee describes the essential job functions affected and the accommodation requested, then use the HR review section to document follow-up questions or next steps.
- 5. Close the loop by recording the outcome, any approved accommodation duration, and the next review date so renewals and changes are easy to track.
Best practices
- Mark only the fields you truly need as required, and keep supporting documentation optional unless your policy specifically requires it.
- Use a date picker for request date, start date needed, and next review date so employees do not enter inconsistent date formats.
- Phrase the limitation field to invite functional impact, not diagnosis details, so the form stays focused on accommodation needs rather than medical history.
- Include a clear line that explains who will see the submission and what happens after it is sent, especially if HR, a manager, or an accommodation coordinator will review it.
- Use progressive disclosure to reveal documentation, alternate contact, or meeting accessibility fields only when the employee indicates they are needed.
- Keep the essential job functions field tied to the actual role so reviewers can assess the request against job requirements instead of vague duties.
- Provide an accessible contact method and keyboard-friendly controls so the form works for employees using assistive technology.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
Who should use this ADA Accommodation Request Form?
Use this form when an employee needs a workplace accommodation related to a disability or medical limitation and HR needs a consistent way to document the request. It works well for managers, HR generalists, and accommodation coordinators who need to collect only the information required to begin review. The form is not meant to diagnose a condition; it is meant to capture the request, the job functions affected, and the next step in the interactive process.
What kinds of requests does this template cover?
This template fits requests for schedule changes, equipment adjustments, workstation modifications, communication supports, leave-related accommodations, and other job-specific changes. It is designed around the employee’s limitation and the essential job functions affected, so it can handle a wide range of roles. If your process requires a separate medical certification or provider form, this template can link to that step without collecting extra PII here.
How often should an accommodation request form be used?
Use it each time an employee initiates a new request, asks to change an existing accommodation, or needs a renewal review for a time-limited accommodation. It also helps when the employee’s role changes and the essential job functions need to be reassessed. For ongoing accommodations, the form can be reused as the front door to a new review cycle rather than relying on email threads.
Who should complete the form and who reviews it?
The employee typically completes the request fields, while HR or an accommodation specialist reviews the submission and coordinates next steps. Managers may provide context about essential job functions, but they should not be the only decision-maker. The HR review section gives your team a place to record status, follow-up, and next review dates so the process stays auditable.
What should we avoid collecting on this form?
Collect only what you need to evaluate the request and start the interactive process, in line with data minimization. Avoid asking for diagnosis details, unrelated medical history, or extra PII that does not affect the accommodation decision. If supporting documentation is needed, keep the field focused on the type of documentation and where it is stored rather than embedding sensitive details in free text.
How does this template support ADA and accessibility requirements?
The form supports ADA workflows by prompting for the limitation, the job functions affected, and the accommodation requested, which are the core inputs needed for review. It should be configured with clear required versus optional fields, accessible labels, keyboard-friendly controls, and progressive disclosure so employees are not overwhelmed. If the form is public-facing or self-service, it should also meet WCAG 2.1 AA expectations for accessibility.
Can we customize this form for different departments or roles?
Yes. You can add conditional logic so the form shows role-specific essential job functions, department-specific manager fields, or different follow-up questions for office, field, or shift-based work. Keep the core structure intact so every request still captures the same review essentials, then tailor the supporting fields to your internal process. That makes it easier to compare requests and maintain a consistent audit trail.
What happens after an employee submits the form?
After submission, HR should acknowledge receipt, review the request for completeness, and schedule the interactive process if needed. The form’s review section can track status, follow-up required, and the next review date so the employee is not left wondering what happens next. A clear confirmation message should tell the employee who will contact them and whether any additional documentation is needed.
How is this different from handling accommodation requests by email?
Email can work for a one-off conversation, but it often leaves gaps in required fields, creates inconsistent records, and makes follow-up harder to track. This template standardizes the request, supports confidentiality, and creates a cleaner audit trail for HR. It also reduces back-and-forth by using structured fields and conditional logic instead of long message threads.
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