REASONABLE ACCOMMODATION REQUEST

Americans with Disabilities Act - Title I Employment

SECTION A: EMPLOYEE ACCOMMODATION REQUEST FORM

PART I: EMPLOYEE INFORMATION

Date of Request: _______________________

Full Legal Name: _______________________

Employee ID Number: _______________________

Department: _______________________

Job Title: _______________________

Supervisor Name: _______________________

Work Location: _______________________

Date of Hire: _______________________

Employment Status:
☐ Full-Time
☐ Part-Time
☐ Temporary
☐ Contractor

Contact Information:

Work Phone: _______________________

Personal Phone: _______________________

Email: _______________________

Preferred Method of Contact:
☐ Work Phone
☐ Personal Phone
☐ Email
☐ In-Person Meeting

PART II: NATURE OF REQUEST

What accommodation(s) are you requesting?

Please describe the specific accommodation(s) you are seeking. Be as detailed as possible.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

When do you need this accommodation to begin?

☐ Immediately
☐ Within 2 weeks
☐ By specific date: _______________________
☐ Ongoing/Permanent
☐ Other: _______________________

Is this a:
☐ New accommodation request
☐ Modification of existing accommodation
☐ Renewal of temporary accommodation

If modification or renewal, describe current/previous accommodation:

_____________________________________________________________________________

PART III: DISABILITY INFORMATION

The ADA protects individuals with disabilities who can perform the essential functions of their job with or without reasonable accommodation.

Note: You are not required to disclose your specific diagnosis. However, you must explain how your condition limits your ability to perform your job functions.

Do you have a physical or mental impairment that substantially limits one or more major life activities?
☐ Yes
☐ No

Which major life activity(ies) are affected by your condition?

☐ Walking
☐ Standing
☐ Sitting
☐ Lifting
☐ Bending
☐ Reaching
☐ Seeing
☐ Hearing
☐ Speaking
☐ Breathing
☐ Learning
☐ Reading
☐ Concentrating
☐ Thinking
☐ Communicating
☐ Sleeping
☐ Eating
☐ Working
☐ Caring for oneself
☐ Performing manual tasks
☐ Operation of major bodily function (specify): _______________________
☐ Other: _______________________

How does your condition limit your ability to perform your job?

Describe the specific job functions or activities affected by your condition:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Is your condition:
☐ Permanent/Ongoing
☐ Temporary (expected duration: _______________________)
☐ Episodic/Intermittent

PART IV: JOB FUNCTIONS AFFECTED

Essential Functions of Your Position:

List the essential functions of your job that are affected by your disability:

How will the requested accommodation help you perform these essential functions?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

PART V: REQUESTED ACCOMMODATIONS

Please check all accommodations you are requesting:

Physical Workspace Modifications

☐ Accessible parking space
☐ Accessible workstation/desk
☐ Ergonomic chair or seating
☐ Standing desk or sit-stand workstation
☐ Modified workspace location
☐ Private office or workspace
☐ Accessible restroom facilities
☐ Temperature/lighting adjustments
☐ Noise reduction measures
☐ Other: _______________________

Equipment and Technology

☐ Screen reader software
☐ Screen magnification software
☐ Voice recognition software
☐ Alternative keyboard/mouse
☐ Braille display
☐ Assistive listening device
☐ Amplified telephone
☐ TTY/TDD equipment
☐ CCTV/video magnifier
☐ Specialized software: _______________________
☐ Other equipment: _______________________

Schedule Modifications

☐ Modified work hours
☐ Flexible start/end times
☐ Part-time or reduced schedule
☐ Additional breaks
☐ Leave for medical appointments
☐ Work from home/remote work
☐ Modified shift assignment
☐ Other: _______________________

Job Restructuring

☐ Reassignment of marginal functions
☐ Exchange of tasks with coworkers
☐ Modified job duties
☐ Restructured job responsibilities
☐ Other: _______________________

Communication Accommodations

☐ Sign language interpreter
☐ Real-time captioning (CART)
☐ Written materials in alternative formats
☐ Additional time for written communications
☐ Preferred communication method: _______________________
☐ Other: _______________________

Policy Modifications

☐ Modified attendance policy
☐ Modified dress code
☐ Permission for service animal
☐ Modified performance evaluation process
☐ Modified training methods
☐ Other: _______________________

Leave-Related Accommodations

☐ Extended leave beyond FMLA
☐ Intermittent leave
☐ Leave for treatment
☐ Graduated return to work
☐ Other: _______________________

Other Accommodations

☐ Job coach or support person
☐ Reassignment to vacant position
☐ Modified supervision methods
☐ Additional training time
☐ Other (specify): _______________________

PART VI: SUPPORTING DOCUMENTATION

Have you consulted with a healthcare provider about this accommodation?
☐ Yes
☐ No

If yes:

Healthcare Provider Name: _______________________

Provider Specialty: _______________________

Provider Phone: _______________________

Provider Address: _______________________

Are you willing to provide medical documentation to support your request?
☐ Yes
☐ No

Note: Your employer may request limited medical documentation to verify:
1. That you have a disability covered by the ADA
2. Your functional limitations related to the accommodation request
3. Why the requested accommodation is needed

Your employer may NOT request:
- Your complete medical records
- Your specific diagnosis (unless necessary to understand limitations)
- Information about conditions unrelated to the accommodation request

PART VII: PREVIOUS ACCOMMODATIONS

Have you previously requested or received workplace accommodations?
☐ No
☐ Yes

If yes, please describe:

Have you received accommodations at previous employers for similar conditions?
☐ No
☐ Yes

If yes, describe what worked well:

_____________________________________________________________________________

_____________________________________________________________________________

PART VIII: EMPLOYEE CERTIFICATION

I certify that the information provided in this request is true and accurate to the best of my knowledge. I understand that:

☐ My employer will engage in an interactive process to determine appropriate accommodations

☐ I may be asked to provide medical documentation from a healthcare provider

☐ Accommodations will be evaluated on a case-by-case basis

☐ My employer may propose alternative accommodations that effectively address my limitations

☐ Information related to my disability will be kept confidential as required by law

☐ Providing false information may result in denial of the accommodation request and/or disciplinary action

Employee Signature: _______________________ Date: _______________________

Printed Name: _______________________

SECTION B: EMPLOYER RESPONSE AND INTERACTIVE PROCESS

PART IX: INITIAL EMPLOYER ACKNOWLEDGMENT

Request Received By: _______________________

Title: _______________________

Date Received: _______________________

Request Forwarded To:
☐ Human Resources
☐ ADA Coordinator
☐ Supervisor
☐ Other: _______________________

Date Employee Notified of Receipt: _______________________

Method of Notification:
☐ Email
☐ Written letter
☐ In-person meeting
☐ Phone call

PART X: INTERACTIVE PROCESS DOCUMENTATION

Interactive Process Meeting(s):

Medical Documentation:

☐ Not required
☐ Requested on: _______________________
☐ Received on: _______________________
☐ Additional information needed: _______________________

Job Accommodation Network (JAN) Consulted:
☐ No
☐ Yes - Recommendations: _______________________

Other Resources Consulted:

_____________________________________________________________________________

PART XI: EMPLOYER DETERMINATION

Date of Determination: _______________________

Determination Made By: _______________________

Title: _______________________

Determination:

☐ APPROVED - Accommodation request approved as submitted

☐ APPROVED WITH MODIFICATIONS - Alternative accommodation approved

☐ PARTIALLY APPROVED - Some accommodations approved

☐ DENIED - Accommodation request denied

☐ ADDITIONAL INFORMATION NEEDED - Request pending further information

If Approved or Approved with Modifications:

Accommodation(s) to be Provided:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Implementation Date: _______________________

Duration:
☐ Permanent
☐ Temporary (end date: _______________________)
☐ Subject to periodic review

Review Date (if applicable): _______________________

Responsible Party for Implementation: _______________________

If Denied:

Reason for Denial (check all that apply):

☐ Accommodation would create undue hardship
☐ Accommodation would fundamentally alter essential job functions
☐ Employee is not a qualified individual with a disability
☐ Insufficient documentation of disability or need
☐ Requested accommodation not effective for stated limitations
☐ Direct threat to health/safety that cannot be eliminated
☐ Other: _______________________

Detailed Explanation of Denial:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Alternative Accommodations Considered:

_____________________________________________________________________________

_____________________________________________________________________________

Were alternative accommodations offered?
☐ No
☐ Yes - Describe: _______________________

PART XII: SIGNATURES

Employer Representative:

Signature: _______________________ Date: _______________________

Printed Name: _______________________

Title: _______________________

Employee Acknowledgment of Decision:

I acknowledge receipt of this determination regarding my accommodation request.

☐ I accept the accommodation as provided
☐ I wish to appeal this determination
☐ I wish to discuss alternative accommodations

Signature: _______________________ Date: _______________________

Printed Name: _______________________

STATE-SPECIFIC NOTES

CALIFORNIA

• California Fair Employment and Housing Act (FEHA): Provides broader protections than federal ADA. Applies to employers with 5+ employees (vs. 15+ for ADA).
• Interactive Process Requirement: California places strong emphasis on the good-faith interactive process. Failure to engage may itself be a violation.
• Broader Definition of Disability: FEHA uses a more expansive definition that covers more conditions than federal ADA.
• No Undue Hardship for Small Employers: FEHA's undue hardship analysis is more employee-friendly.
• DFEH Complaints: California Department of Fair Employment and Housing handles state claims.

TEXAS

• Texas Labor Code Chapter 21: State employment discrimination law mirrors many ADA provisions.
• Texas Workforce Commission (TWC): Handles state employment discrimination complaints.
• 15-Employee Threshold: Texas law applies to employers with 15+ employees, same as federal ADA.
• 180-Day Filing Deadline: Complaints to TWC must be filed within 180 days of the discriminatory act.

FLORIDA

• Florida Civil Rights Act (Fla. Stat. Section 760.01 et seq.): State anti-discrimination law.
• Florida Commission on Human Relations: State agency handling discrimination complaints.
• 15-Employee Threshold: Applies to employers with 15+ employees.
• 365-Day Filing Deadline: Generally one year to file state complaint.

NEW YORK

• New York Human Rights Law: Provides broader protections than federal ADA. Applies to employers with 4+ employees.
• Broader Disability Definition: More expansive than federal ADA.
• NYC Human Rights Law: Even broader protections within New York City; applies to employers with 4+ employees.
• Interactive Process: Strong emphasis on good-faith engagement.
• Division of Human Rights: State agency handling complaints.

EMPLOYER GUIDANCE: THE INTERACTIVE PROCESS

Required Steps

1. Acknowledge Receipt: Respond to accommodation requests promptly (best practice: within 5-7 business days).

2. Gather Information: Request only necessary medical documentation. Do NOT request complete medical records or unrelated health information.

3. Engage in Interactive Process: Meet with the employee to discuss:
   - Nature of limitations
   - Essential job functions affected
   - Possible accommodations
   - Employee's preferences

4. Identify Effective Accommodations: Consider:
   - Employee's suggested accommodation
   - Alternative accommodations
   - Job Accommodation Network (JAN) resources (1-800-526-7234)

5. Document Everything: Maintain records of all discussions, documentation, and decisions.

6. Make Timely Decision: Unreasonable delays may violate the ADA.

7. Implement Accommodation: Provide the accommodation and monitor effectiveness.

8. Follow Up: Check in with employee; modify accommodation if needed.

Undue Hardship Factors (per EEOC)

If claiming undue hardship, document analysis of:
- Nature and net cost of accommodation
- Overall financial resources of the facility
- Number of employees at the facility
- Effect on expenses and resources
- Overall financial resources of the employer
- Type of operation and structure of workforce
- Impact on the operation of the facility

Resources

• Job Accommodation Network (JAN): 1-800-526-7234 / askjan.org
• EEOC: 1-800-669-4000 / eeoc.gov
• ADA National Network: adata.org

APPENDIX: SAMPLE MEDICAL DOCUMENTATION REQUEST LETTER

[EMPLOYER LETTERHEAD]

Date: [Date]

To: [Healthcare Provider Name]
From: [Employer Representative Name and Title]
Re: ADA Accommodation - Medical Documentation Request

Dear [Healthcare Provider]:

Our employee, [Employee Name], has requested a reasonable accommodation under the Americans with Disabilities Act. To evaluate this request, we need limited medical information.

Please provide the following information only:

1. Does the employee have a physical or mental impairment?
   ☐ Yes ☐ No

2. What major life activity(ies) does this impairment substantially limit?
   _____________________________________________

3. What functional limitations does the employee experience in the workplace?
   _____________________________________________

4. Is the requested accommodation ([describe accommodation]) medically necessary?
   ☐ Yes ☐ No

5. If the requested accommodation is not appropriate, what accommodation(s) would you recommend?
   _____________________________________________

6. Expected duration of the condition:
   ☐ Permanent ☐ Temporary (expected duration: _________)

IMPORTANT: We are NOT requesting:
- Complete medical records
- Specific diagnosis (unless necessary to understand limitations)
- Information about unrelated conditions

Please return this form to: [Contact Information]

Questions? Contact: [Name, Phone, Email]

This template reflects ADA reasonable accommodation requirements as of January 2026. The EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship remains the primary interpretive resource. Consult current EEOC guidance and legal counsel for specific situations.