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Run: ADA Accommodation Request Form

Collect ADA accommodation requests in one place so HR can document the need, review essential job functions, and move the interactive process forward with le...

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Employee Information

Employee Name (required)

Employee ID

Job Title (required)

Department (required)

Work Location

Preferred Contact Method (required)

Accommodation Request

Accommodation Requested (required)

Briefly describe the accommodation you are requesting.

Workplace Barrier or Limitation (required)

Describe the job task, workplace condition, or barrier that is making accommodation necessary.

Essential Job Functions Affected (required)

Identify the essential functions of your job that are affected by the limitation.

Type of Accommodation Requested (required)

Requested Start Date

Is this request temporary or ongoing? (required)

Medical Documentation

Supporting Documentation Attached? (required)

Type of Documentation

Documentation Notes

Add any notes about the documentation you are submitting or plan to submit.

Do you need help obtaining documentation?

Yes No N/A

Interactive Process Preferences

Preferred Meeting Format

Communication Accommodations Needed

Describe any communication format or accessibility needs for the review process.

Alternative Accommodations Considered

List any alternative accommodations you would be willing to consider.

Is there an urgent need for this request? (required)

Employee Certification

Certification (required)

Yes No N/A

Employee Signature (required)

Date (required)

Get your results

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Email (required)

Your name (optional)

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