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Run: ADA Reasonable Accommodation Request

Use this ADA Reasonable Accommodation Request form to start the interactive process, document the workplace barrier, and capture only the information needed ...

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Employee Information

Employee name (required)

Employee ID

Optional if your organization uses employee IDs for routing.

Work email (required)

Department (required)

Manager name

Accommodation Request

What are you requesting? (required)

Describe the accommodation you are requesting (required)

Explain what adjustment would help you perform the essential functions of your job.

What workplace barrier or limitation is this request meant to address? (required)

Describe the work-related difficulty without sharing more medical detail than necessary.

Which essential job functions are affected?

Select all that apply.

Is this request temporary or ongoing? (required)

Supporting Information

Are you submitting supporting documentation? (required)

Upload supporting documentation

Optional. Upload only documents relevant to the accommodation request.

Additional context

Optional. Share any other information that would help HR understand the request.

Consent and Review

I understand this form may include PII or medical information and will be handled confidentially to the extent required by law. (required)

Yes No N/A

I consent to HR contacting me to discuss this request and participate in the interactive process. (required)

Yes No N/A

Employee signature (required)

Submission date (required)

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Email (required)

Your name (optional)

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