REMOTE WORK ACCOMMODATION REQUEST FORM

IMPORTANT NOTICE TO EMPLOYEES

You have the right to request reasonable accommodations for a disability under the Americans with Disabilities Act (ADA) and applicable state laws. Remote work may be a reasonable accommodation depending on your position and circumstances.

Key Points:
- You do not need to use any specific words or forms to request an accommodation
- You do not need to disclose your specific diagnosis
- You do need to explain how your disability affects your ability to work on-site
- Your medical information will be kept confidential
- We will engage in an interactive process to explore accommodation options
- Providing false information may result in disciplinary action

If you need assistance completing this form, please contact [HR Contact Name] at [Email/Phone].

SECTION 1: EMPLOYEE INFORMATION

Employee Name: ________________________________________
Employee ID: __________________________________________
Position/Title: _______________________________________
Department: ___________________________________________
Manager: ______________________________________________
Work Location: ________________________________________
Hire Date: ___________________________________________
Date of Request: ______________________________________
HR Contact: ___________________________________________

SECTION 2: ACCOMMODATION REQUEST

2.1 Type of Accommodation Requested

I am requesting the following accommodation:

☐ Full-time remote work - Work from home 100% of the time
☐ Partial remote work / Hybrid - Work from home [Number] days per week
☐ Temporary remote work - Work from home for [Duration]
☐ Flexible remote work - Ability to work from home when needed
☐ Other arrangement: ___________________________________

2.2 Proposed Schedule

If requesting partial remote work:
- Requested remote days: ☐ Mon ☐ Tue ☐ Wed ☐ Thu ☐ Fri
- Requested in-office days: ☐ Mon ☐ Tue ☐ Wed ☐ Thu ☐ Fri
- Flexibility needed: ☐ Fixed schedule ☐ Flexible based on symptoms

2.3 Duration

☐ Permanent / Indefinite
☐ Temporary: From ____________ to ____________
☐ For review and reassessment after: ____________
☐ Other: _________________________________________________

2.4 Remote Work Location

Address where you would work from home:
_________________________________________________________
City: _________________ State: _______ ZIP: ______________

SECTION 3: LIMITATION AND ACCOMMODATION NEED

3.1 Nature of Limitation

Please describe, in general terms, how your condition affects your ability to work on-site. You do NOT need to disclose your specific diagnosis.

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

3.2 Why Remote Work Would Help

Please explain how working remotely would address your limitations and enable you to perform your job:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

3.3 Current Challenges

Describe any challenges you currently face working on-site:

☐ Commuting difficulties due to:
_________________________________________________________

☐ On-site environmental factors (describe):
_________________________________________________________

☐ Frequency of medical appointments/treatments:
_________________________________________________________

☐ Need for rest periods or flexible schedule:
_________________________________________________________

☐ Other factors:
_________________________________________________________

3.4 Essential Functions

Please describe how you would perform your job's essential functions while working remotely:

3.5 Alternative Accommodations

Are there other accommodations (besides remote work) that might address your limitations?

☐ Modified work schedule: _________________________________
☐ Modified workspace/equipment: ____________________________
☐ Transfer to different position: __________________________
☐ Leave of absence: ______________________________________
☐ Other: ________________________________________________
☐ I believe remote work is the only effective accommodation

SECTION 4: TECHNOLOGY AND WORKSPACE

4.1 Technology Capabilities

I confirm that at my proposed remote work location:
☐ I have or can obtain reliable internet service
☐ I have or can set up a dedicated workspace
☐ I have necessary equipment or need Company to provide:
☐ Computer ☐ Monitor ☐ Keyboard/Mouse ☐ Headset
☐ Other: ____________________________________________

4.2 Communication

I confirm that I can:
☐ Participate in video calls and meetings
☐ Respond to communications during work hours
☐ Be available during core business hours: [Hours]
☐ Communicate any availability limitations in advance

4.3 Supervision

I confirm that:
☐ I can work productively with remote supervision
☐ I can meet performance expectations while working remotely
☐ I will maintain regular communication with my manager

SECTION 5: MEDICAL DOCUMENTATION

5.1 Medical Support

☐ I am attaching medical documentation supporting this request
☐ I will provide medical documentation upon request
☐ My healthcare provider can be contacted for verification:

Healthcare Provider:
Name: ___________________________________________________
Practice/Facility: ______________________________________
Phone: __________________________________________________
Fax: ____________________________________________________
Email: __________________________________________________

5.2 Authorization to Contact Healthcare Provider

☐ I authorize [Company Name] to contact my healthcare provider to obtain information necessary to evaluate this accommodation request. (See separate Medical Information Release form)

☐ I do not authorize contact at this time but will provide documentation directly.

5.3 Documentation You May Be Asked to Provide

The Company may request documentation from your healthcare provider that includes:
- Confirmation that you have a condition that qualifies as a disability under the ADA
- Description of how your condition limits your ability to work on-site
- An opinion on whether remote work would be an effective accommodation
- Any restrictions or limitations on your work activities
- Estimated duration of need for accommodation

Note: The Company will NOT ask for your specific diagnosis unless it is necessary to understand your limitations and evaluate the accommodation.

SECTION 6: INTERACTIVE PROCESS

6.1 Interactive Process Overview

The ADA requires employers and employees to engage in an "interactive process" to identify effective accommodations. This means:

☐ We will discuss your request and limitations
☐ We will explore whether remote work is feasible for your position
☐ We may discuss alternative accommodations
☐ We may request additional medical information
☐ We will make a decision in a timely manner
☐ The process is collaborative, not adversarial

6.2 Your Participation

To facilitate the interactive process, please:
☐ Respond to requests for information promptly
☐ Provide requested medical documentation in a timely manner
☐ Participate in meetings to discuss your request
☐ Consider alternative accommodations if suggested
☐ Inform us if your condition or needs change

6.3 Timeline

While there is no specific deadline required by law, we aim to:
☐ Acknowledge your request within [3] business days
☐ Begin the interactive process within [5] business days
☐ Request any needed medical information within [10] business days
☐ Make a decision within [30] days of receiving complete information

SECTION 7: CERTIFICATION AND SIGNATURE

7.1 Employee Certification

By signing below, I certify that:

☐ I have a condition that substantially limits one or more major life activities
☐ The information provided in this form is true and accurate to the best of my knowledge
☐ I understand that providing false information may result in denial of the request and/or disciplinary action
☐ I understand that I may be asked to provide medical documentation
☐ I will participate in good faith in the interactive process
☐ I understand that accommodation requests are evaluated individually
☐ I understand that not all requests can be granted (e.g., if they would cause undue hardship or if essential functions cannot be performed remotely)

7.2 Confidentiality Acknowledgment

☐ I understand that my medical information will be kept confidential
☐ I understand that only those with a need to know will have access to information about my accommodation
☐ I understand that my medical information will be kept separate from my general personnel file

7.3 Signature

Employee Signature: _____________________________________

Date: __________________________________________________

SECTION 8: FOR HR USE ONLY

8.1 Request Receipt

☐ Request received: [Date]
☐ Request acknowledged to employee: [Date]
☐ Assigned to: [HR Representative Name]
☐ Manager notified: [Date]

8.2 Interactive Process Log

8.3 Position Analysis

Essential functions of the position:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________
5. _________________________________________________

Can essential functions be performed remotely? ☐ Yes ☐ No ☐ Partially

Explain: _______________________________________________
_______________________________________________________

8.4 Medical Documentation Review

☐ Documentation supports existence of disability: ☐ Yes ☐ No ☐ Need more info
☐ Documentation supports need for accommodation: ☐ Yes ☐ No ☐ Need more info
☐ Additional information requested: [Date]
☐ Additional information received: [Date]

8.5 Undue Hardship Analysis (if applicable)

If considering denial based on undue hardship, document analysis:
☐ Cost of accommodation: ________________________________
☐ Impact on operations: _________________________________
☐ Impact on other employees: ____________________________
☐ Nature of business: ___________________________________
☐ Overall financial resources: ___________________________

8.6 Alternative Accommodations Considered

8.7 Decision

☐ APPROVED - Remote work accommodation granted
- Type: ☐ Full-time ☐ Partial ☐ Temporary ☐ Other
- Duration: _________________________________________
- Conditions: _______________________________________
- Review date: ______________________________________

☐ APPROVED WITH MODIFICATIONS
- Describe: ________________________________________
- _________________________________________________

☐ DENIED
- Reason: ☐ Undue hardship ☐ Essential functions cannot be performed
☐ Not a qualified individual ☐ Other: _______________
- Explanation: _____________________________________
- Alternatives offered: _____________________________

☐ ADDITIONAL INFORMATION NEEDED
- Information requested: ____________________________
- From: ☐ Employee ☐ Healthcare provider
- Deadline: ________________________________________

8.8 Decision Communication

☐ Employee notified of decision: [Date]
☐ Method: ☐ In person ☐ Video call ☐ Phone ☐ Written
☐ Written confirmation provided: [Date]
☐ Appeal rights communicated: ☐ Yes

8.9 Sign-Off

HR Representative: ____________________ Date: ___________
Manager Review: _______________________ Date: ___________
Legal Review (if applicable): ___________ Date: ___________

APPENDIX A: MEDICAL INFORMATION RELEASE FORM

Authorization to Release Medical Information

I, [Employee Name], authorize the following healthcare provider(s) to release medical information to [Company Name] for the purpose of evaluating my reasonable accommodation request:

Healthcare Provider: _____________________________________
Address: ________________________________________________
Phone/Fax: ______________________________________________

Information to be Released:
☐ Confirmation that I have a condition that qualifies as a disability under the ADA
☐ Description of how my condition affects my ability to work on-site
☐ Opinion on whether remote work would be an effective accommodation
☐ Restrictions or limitations on work activities
☐ Estimated duration of need for accommodation
☐ Other: ________________________________________________

Information NOT to be Released:
☐ Specific diagnosis (unless necessary for accommodation evaluation)
☐ Complete medical records
☐ Information unrelated to the accommodation request

Duration: This authorization is valid for [90] days from the date signed.

Right to Revoke: I understand I may revoke this authorization at any time in writing.

Employee Signature: _____________________ Date: ___________

APPENDIX B: HEALTHCARE PROVIDER CERTIFICATION

To Be Completed by Healthcare Provider

Patient: ___________________________________________
Date of Evaluation: _________________________________

1. Does this patient have a physical or mental impairment that substantially limits one or more major life activities?
   ☐ Yes ☐ No

2. Without revealing the specific diagnosis, please describe how the patient's condition affects their ability to perform work activities on-site:
   ___________________________________________________________
   ___________________________________________________________

3. In your medical opinion, would working remotely (from home) be an effective accommodation for this patient's condition?
   ☐ Yes ☐ No ☐ Partially

4. Please explain:
   ___________________________________________________________
   ___________________________________________________________

5. Are there any restrictions or limitations on the patient's work activities?
   ___________________________________________________________
   ___________________________________________________________

6. How long do you anticipate the patient will need this accommodation?
   ☐ Temporary: ____________________________________________
   ☐ Permanent / Indefinite

7. Are there any other accommodations that might be effective?
   ___________________________________________________________

Healthcare Provider Certification:
I certify that the information provided above is accurate based on my evaluation of this patient.

Provider Name: __________________________________________
Credentials: ____________________________________________
Practice/Facility: ______________________________________
Address: ________________________________________________
Phone: __________________________________________________
Signature: ______________________________________________
Date: ___________________________________________________

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