Templates › Forms › SEO page

Run: 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...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Employee Information

Employee name (required)

Employee ID

Work email (required)

Department (required)

Job title (required)

Manager name

Accommodation Request

Date of request (required)

Type of accommodation requested (required)

Describe the workplace barrier or limitation (required)

Explain what task, environment, policy, or communication barrier is affecting your ability to perform your job.

Essential job functions affected (required)

Select the essential functions impacted by the barrier.

Requested accommodation details (required)

Describe the specific accommodation(s) you are requesting and how they would help.

Is this request time-sensitive? (required)

Medical or Supporting Information

Do you have supporting medical documentation available? (required)

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? (required)

Additional supporting information

Optional. Include any information that helps explain the need for accommodation.

Interactive Process Preferences

Preferred contact method (required)

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

I consent to HR processing this request for the purpose of evaluating a workplace accommodation. (required)

Yes No N/A

I understand that information provided will be handled confidentially and shared only on a need-to-know basis. (required)

Yes No N/A

I certify that the information provided is true and complete to the best of my knowledge. (required)

Yes No N/A

Employee signature (required)

Submission date (required)

HR Review Details

Reviewer name

Review date

Review status

Approved accommodation

Implementation notes

Follow-up date

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free