This template is designed for employees or applicants to formally request accommodations for disabilities as per the Americans with Disabilities Act (ADA) and the Rehabilitation Act, detailing their specific needs, impairment nature, desired accommodations, and necessary medical documentation (employees only).
It also outlines the process for Human Resources to review, implement or deny these requests, and ensure confidentiality and adherence to ADA guidelines.
Remember: The goal of the ADA Accommodation Request Form is to comply with legal requirements and create an inclusive and supportive work environment for all employees, including those with disabilities.
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This form complies with the Americans with Disabilities Act (ADA) and the Rehabilitation Act by providing a process for employees or applicants to request reasonable accommodations. The information provided will be kept confidential in accordance with ADA guidelines. For any queries or additional information regarding this form or the accommodation process, please contact the Human Resources Department.
Employee Name: ________________________________
Job Title: ________________________________________
Phone: __________________________________________
Department: ____________________________________
Work Email: _____________________________________
A. Questions to clarify accommodation requested.
What specific accommodation are you requesting? ______________
Detail the reasonable accommodation you are requesting to assist with performing the essential job functions or to participate in the application process.If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore? Yes __ No__
If yes, please explain: _____________If known, please suggest any specific accommodation(s), such as telework, assistive technology, modified work schedule, or other adjustments that would assist you.]
What is the nature of impairment? Briefly describe your impairment under the Americans with Disabilities Act (ADA) or Rehabilitation Act, if applicable.
Is your accommodation request time-sensitive? Yes __ No__
If yes, please explain.
B. Questions to document the reason for the accommodation request.
What, if any, job function are you having difficulty performing? ______________
What, if any, employment benefit are you having difficulty accessing? ______________
What limitation interferes with your ability to perform your job or access an employment benefit? Explain how your impairment affects your ability to perform major life activities or specific functions of your job. ______________
Have you had any accommodations in the past for this same limitation? Yes __ No__
If yes, what were they and how effective were they? ______________
If you are requesting a specific accommodation, how will that accommodation assist you in fulfilling the essential functions of your job?
C. Other
Please provide any additional information that might be useful in
processing your accommodation request: ______________
Signature: ____________________________________________
Could you explain how your impairment affects your ability to perform major life activities or specific functions of your job?Signature Date: ____________________________
Return to ____________________________
Human Resources Use Only
Received by: ______________
Date Received: ______________
Accommodation Request Review Process:
The Interactive Process: Detail the steps taken for the interactive process between the employee/applicant and Human Resources to implement the reasonable accommodation.
Determination of reasonable accommodation: Indicate whether the reasonable accommodation request is granted, denied, or if additional information is needed. Include an explanation for the decision and any alternative accommodations offered.
If accommodation not granted, reason for denial (e.g., Undue Hardship): Provide detailed reasoning if the accommodation is deemed to cause undue hardship to the organization.
Implementation Date: __________________
Employee/Applicant Acknowledgment:
Signature: ___________________________________________
Signature Date: _____________________________________
Additional Information:
TTY/TDD Users: Please provide TTY/TDD phone number for hearing-impaired employees.
Contact Information for Equal Employment Opportunity Commission (EEOC):
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Built by 2x disability-focused founders, the software is a workplace ADA and PWFA accommodations platform for progressive companies focused on making workplaces inclusive for everyone. Disclo is a HIPAA-compliant platform that requests, tracks, and manages workplace accommodations—all in one place.
Disclo makes handling accommodations seamless by combining automation, in-app medical e-verification, out-of-the-box analytics (so you can auto-track against EEOC and ADA standards), and the ability to connect to any HRIS and ATS with pre-built integrations.
Strengthen workplace inclusivity and future-proof ADA and PWFA processes while establishing a digital paper trail for your organization. Learn more at disclo.com/demo.
TL;DR This template guides employees or applicants through requesting accommodations under the Americans with Disabilities Act (ADA) and the Rehabilitation Act, emphasizing the need for clarity, privacy, and ADA compliance in the form's design and process. It outlines the steps for submitting accommodation requests, including providing specific details on the impairment and desired accommodations, and details the Human Resources process for reviewing and implementing these requests while ensuring confidentiality.
This template is designed for employees or applicants to formally request accommodations for disabilities as per the Americans with Disabilities Act (ADA) and the Rehabilitation Act, detailing their specific needs, impairment nature, desired accommodations, and necessary medical documentation (employees only).
It also outlines the process for Human Resources to review, implement or deny these requests, and ensure confidentiality and adherence to ADA guidelines.
Remember: The goal of the ADA Accommodation Request Form is to comply with legal requirements and create an inclusive and supportive work environment for all employees, including those with disabilities.
----------------------------------------------------------------------------------------
This form complies with the Americans with Disabilities Act (ADA) and the Rehabilitation Act by providing a process for employees or applicants to request reasonable accommodations. The information provided will be kept confidential in accordance with ADA guidelines. For any queries or additional information regarding this form or the accommodation process, please contact the Human Resources Department.
Employee Name: ________________________________
Job Title: ________________________________________
Phone: __________________________________________
Department: ____________________________________
Work Email: _____________________________________
A. Questions to clarify accommodation requested.
What specific accommodation are you requesting? ______________
Detail the reasonable accommodation you are requesting to assist with performing the essential job functions or to participate in the application process.If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore? Yes __ No__
If yes, please explain: _____________If known, please suggest any specific accommodation(s), such as telework, assistive technology, modified work schedule, or other adjustments that would assist you.]
What is the nature of impairment? Briefly describe your impairment under the Americans with Disabilities Act (ADA) or Rehabilitation Act, if applicable.
Is your accommodation request time-sensitive? Yes __ No__
If yes, please explain.
B. Questions to document the reason for the accommodation request.
What, if any, job function are you having difficulty performing? ______________
What, if any, employment benefit are you having difficulty accessing? ______________
What limitation interferes with your ability to perform your job or access an employment benefit? Explain how your impairment affects your ability to perform major life activities or specific functions of your job. ______________
Have you had any accommodations in the past for this same limitation? Yes __ No__
If yes, what were they and how effective were they? ______________
If you are requesting a specific accommodation, how will that accommodation assist you in fulfilling the essential functions of your job?
C. Other
Please provide any additional information that might be useful in
processing your accommodation request: ______________
Signature: ____________________________________________
Could you explain how your impairment affects your ability to perform major life activities or specific functions of your job?Signature Date: ____________________________
Return to ____________________________
Human Resources Use Only
Received by: ______________
Date Received: ______________
Accommodation Request Review Process:
The Interactive Process: Detail the steps taken for the interactive process between the employee/applicant and Human Resources to implement the reasonable accommodation.
Determination of reasonable accommodation: Indicate whether the reasonable accommodation request is granted, denied, or if additional information is needed. Include an explanation for the decision and any alternative accommodations offered.
If accommodation not granted, reason for denial (e.g., Undue Hardship): Provide detailed reasoning if the accommodation is deemed to cause undue hardship to the organization.
Implementation Date: __________________
Employee/Applicant Acknowledgment:
Signature: ___________________________________________
Signature Date: _____________________________________
Additional Information:
TTY/TDD Users: Please provide TTY/TDD phone number for hearing-impaired employees.
Contact Information for Equal Employment Opportunity Commission (EEOC):
----------------------------------------------------------------------------------------
Built by 2x disability-focused founders, the software is a workplace ADA and PWFA accommodations platform for progressive companies focused on making workplaces inclusive for everyone. Disclo is a HIPAA-compliant platform that requests, tracks, and manages workplace accommodations—all in one place.
Disclo makes handling accommodations seamless by combining automation, in-app medical e-verification, out-of-the-box analytics (so you can auto-track against EEOC and ADA standards), and the ability to connect to any HRIS and ATS with pre-built integrations.
Strengthen workplace inclusivity and future-proof ADA and PWFA processes while establishing a digital paper trail for your organization. Learn more at disclo.com/demo.
