Employment & HR
Reasonable Disability Accommodation Request
Reasonable disability accommodation request under ADA for workplace modifications. 2 signers (employer and employee).
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# Reasonable Disability Accommodation Request **Date:** ___________ This Reasonable Disability Accommodation Request ("Request") is entered into by and between: **Employer:** ___________ ("Employer") **Employee:** ___________ ("Employee") ## 1. Employee Information **Job Title:** ___________ **Department:** ___________ **Date of Hire:** ___________ **Supervisor Name:** ___________ **Work Location:** ___________ ## 2. Nature of Disability **General Description of Condition:** ___________ **Is the Condition:** ___________ **How does the condition affect your ability to perform essential job functions?** ___________ ## 3. Requested Accommodation **Type of Accommodation Requested:** ___________ **Detailed Description of Requested Accommodation:** ___________ **How will this accommodation enable you to perform essential job functions?** ___________ **Requested Start Date:** ___________
Fields (25)
effective date
date 路 required
employer name
text 路 required
employee name
text 路 required
job title
text 路 required
department
text 路 required
date of hire
date 路 required
supervisor name
text 路 required
work location
textarea 路 required
condition description
textarea 路 required
condition duration
select 路 required
functional limitations
textarea 路 required
accommodation type
select 路 required
accommodation details
textarea 路 required
accommodation justification
textarea 路 required
accommodation start date
date 路 required
accommodation duration
select 路 required
provider consulted
select 路 required
healthcare provider
text
provider phone
text
employer response
select 路 required
employer comments
textarea
governing state
select 路 required
employer signer name
text 路 required
employer signer title
text 路 required
employee signer name
text 路 required
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