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Run: 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 ...

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Employee Information

Employee Name (required)

Employee ID

Work Email (required)

Department (required)

Job Title (required)

Manager Name

Accommodation Request

Request Date (required)

Work-Related Limitation or Barrier (required)

Describe the job task, workplace condition, or barrier that is affected by your disability-related need.

Essential Job Functions Affected (required)

Select the essential job functions that are impacted. Choose all that apply.

Requested Accommodation (required)

Describe the accommodation(s) you believe would help you perform the essential functions of your job.

Expected Duration (required)

Date Accommodation Is Needed By

Supporting Information

Are you providing supporting documentation? (required)

Type of Supporting Documentation

Upload Supporting Documents

Additional Notes

Use this field for any other information relevant to the request.

Interactive Process Preferences

Preferred Contact Method (required)

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

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

Yes No N/A

I consent to HR or the designated accommodation coordinator reviewing this information for the purpose of evaluating my accommodation request. (required)

Yes No N/A

I understand this information will be treated as confidential and shared only with those who need it to evaluate or implement the accommodation. (required)

Yes No N/A

HR Review Details

Review Status

Review Notes

Follow-Up Required

Yes No N/A

Next Review Date

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Email (required)

Your name (optional)

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