ADA Accommodation Request Form
An ADA Accommodation Request Form for collecting an employee’s accommodation need, the job barrier, supporting documentation, and HR review in one place. Use it to start the interactive process with clear fields, consent, and follow-up tracking.
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Overview
This ADA Accommodation Request Form template collects the information HR needs to start and document the interactive process: employee details, the barrier affecting work, the essential job functions involved, the accommodation requested, supporting documentation, and the review outcome. It is designed for workplace accommodation requests tied to disability-related needs, not for general employee complaints, performance issues, or leave administration.
Use this template when an employee is asking for a change to schedule, equipment, workspace, communication method, or another work condition that helps them perform essential duties. The form supports progressive disclosure, so you can ask for medical documentation only when needed and keep sensitive fields separate from the request itself. It also includes consent, confidentiality acknowledgment, and follow-up tracking so HR can document what was requested, what was approved, and what happens next.
Do not use this form as a catch-all intake for every HR issue. If the request is unrelated to disability accommodation, a different form is a better fit. Also avoid collecting unnecessary PII or medical detail; the goal is to gather only the minimum information needed to evaluate the request and implement an accommodation. When completed well, this template gives employees a clear path to request help and gives HR a clean record for review, approval, and follow-up.
Standards & compliance context
- This template supports ADA interactive-process documentation by capturing the request, the barrier, and the accommodation under review.
- Confidential medical fields should be access-restricted and collected only when needed to evaluate the request, consistent with minimum-necessary handling.
- The form should include consent and confidentiality language so the employee understands how PII and supporting documentation will be used.
- If the form is public-facing or employee-accessible, it should meet WCAG 2.1 AA expectations for labels, keyboard access, and readable validation messages.
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 exposing medical details.
- Employee name
- Employee ID
- Work email
- Department
- Job title
- Manager name
Accommodation Request
This is the core of the form because it captures the barrier, the job functions affected, and the specific change being requested.
- 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
This section should stay narrow and optional unless documentation is needed, so the form follows minimum-necessary principles.
- 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
This section helps HR communicate in the employee’s preferred format and avoid barriers during the review process.
- 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
This section records consent, confidentiality acknowledgment, and accuracy confirmation so the request can be processed cleanly.
- 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
This section creates the review record, approval status, implementation notes, and follow-up tracking needed to close the loop.
- Reviewer name
- Review date
- Review status
- Approved accommodation
- Implementation notes
- Follow-up date
How to use this template
- 1. Add your organization’s HR contact, confidentiality notice, and any policy language before publishing the form.
- 2. Pre-fill the employee identity fields from your HR system where possible and keep manager routing separate from medical review access.
- 3. Use conditional logic to show documentation upload, provider contact permission, or communication support fields only when they apply.
- 4. Ask the employee to describe the workplace barrier, the essential job functions affected, and the specific accommodation requested in concrete terms.
- 5. Route the submission to HR for review, record the decision and implementation notes, and schedule a follow-up date to confirm the accommodation is working.
Best practices
- Mark required fields clearly and keep optional medical fields separate from the core request to support data minimization.
- Use a date picker for request date, review date, and follow-up date instead of free-text entry.
- Offer multi-select options for accommodation types so employees can choose more than one need without rewriting the form.
- Include a plain-language line that explains what happens after submission, who will see the form, and how confidentiality is handled.
- Use conditional logic to hide documentation and provider-contact fields unless the employee indicates they have supporting information.
- Ask for the essential job functions affected rather than a full job description, so the request stays focused on the actual barrier.
- Provide a communication support field for interpreters, captioning, or alternate formats when the employee needs them.
- Keep implementation notes separate from the employee-facing request so HR can document actions without exposing sensitive details.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is this ADA Accommodation Request Form used for?
This form collects the employee’s request, the workplace barrier, the essential job functions affected, and the accommodation they are asking for. It also captures supporting documentation, communication preferences, and HR review details so the interactive process has a clear record. Use it when an employee needs a workplace change tied to a disability-related limitation.
Who should complete this form and who should review it?
The employee usually completes the request sections, while HR or an assigned reviewer completes the review fields. A manager may be listed for routing, but the form should not require the manager to diagnose, evaluate, or approve medical details. Keep medical information limited to HR or another designated confidential reviewer.
How often is this form used?
Use it each time an employee requests a new accommodation, asks to change an existing one, or needs a follow-up review after implementation. It is not a one-time onboarding form because accommodation needs can change with job duties, work location, or medical guidance. The follow-up date field helps track ongoing adjustments.
What should be included in the request, and what should be left out?
Include the barrier, the essential job functions affected, the accommodation requested, and any support needed for communication or meetings. Leave out unnecessary medical history, diagnosis details, or unrelated personal information unless it is needed to evaluate the request. This supports data minimization and keeps the form focused on what HR actually needs.
Can the employee submit this form anonymously?
No. An ADA accommodation request generally needs to be tied to a specific employee so HR can start the interactive process and document the outcome. If your organization also uses anonymous feedback or hotline forms, keep those separate from this template. This form should instead include a clear confidentiality notice and consent to process the request.
How should medical documentation be handled?
Make documentation optional unless your policy or the situation requires it, and use a dedicated upload field with restricted access. The form should state who can view the file, how it will be stored, and whether provider contact permission is being granted. Avoid collecting more medical detail than needed to evaluate the accommodation.
What are common mistakes when using this form?
Common mistakes include making every field required, asking for diagnosis details that are not necessary, and skipping the follow-up step after an accommodation is approved. Another issue is using free-text fields where a date picker, checkbox, or multi-select would be more accurate. The form should also clearly explain what happens after submission so employees know the next step.
How can this form be customized for different roles or departments?
Use conditional logic to show only the fields that apply to the request type, such as schedule changes, equipment needs, remote work, or communication support. You can also add department-specific fields for essential job functions or manager routing without changing the core request flow. Keep the structure consistent so HR can compare requests and maintain an audit trail.
Can this form connect to HR systems or ticketing tools?
Yes. The review fields can map to an HR case management workflow, and the submission can trigger notifications to HR, the manager, or an accommodation coordinator. If you integrate it, preserve confidentiality by limiting access to medical attachments and sensitive notes. A clear status field also makes it easier to track approval, implementation, and follow-up.
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