Request for Accommodation
This attorney drafted request for accommodation sets forth a form
an employer could provide to an employee who is requesting
work place accommodations as a result of employee’s disability.
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EXPRESS, IMPLIED, OR OTHERWISE, INCLUDING AS TO THEIR LEGAL EFFECT AND
COMPLETENESS. They are for guidance and should be modified to meet your needs and the
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modifying any form is not creating or entering into an Attorney-Client relationship. Docstoc
© Copyright 2012 Docstoc Inc. does not provide legal advice. The information and forms are not a 1substitute for the advice of
your own attorney.
[Instruction: Insert company logo/letterhead here.]
Request for Accommodation
If you believe you may need an employment accommodation because of a disability, please
complete this form and send it in a sealed envelope to _____. [Instruction: Insert contact name
and information.] If there is not enough space on the form for your answers, please add pages
as necessary. In addition, please include a copy of your job description or information about the
nature of your job responsibilities at _____ [Instruction: Insert company name.] (“Company”),
along with any additional information you think might be helpful in reviewing your request. The
information you provide will assist Company in determining whether, and/or to what extent,
reasonable accommodations may be required for you to perform the essential functions of your
job. The Company will keep the form you complete confidential and separate from your
personnel file. However, the form and other information you provide may be shared with
health care providers (see below).
TO: _____ [Instruction: Insert contact name and information.]
FROM: ___________________________________________________
Name
___________________________________________________
Social Security Number
___________________________________________________
Address
___________________________________________________
Phone Number
___________________________________________________
Job Title
1. Identify and describe the impairment that is the basis for your request for reasonable
accommodations (see the definition of disability at the end of this form). What major life
activity is substantially limited by your condition? Is the impairment permanent or
temporary? How long have you had it?__________________________________________
2. Do you use any mitigating measures – such as eyeglasses, contact lenses, high blood pressure
medicine or hearing aids – that help reduce the impact of your disability on your ability to
perform your job? If so, please describe them and how they affect your job performance.
________________________________________________________________________
3. Identify and describe the essential function(s) of the position that you are unable to perform
without reasonable accommodations (see definition of reasonable accommodation at the end
of this form):________________________________________________________________
4. Identify and describe the accommodation(s) you believe you need to enable you to perform
the essential functions of your position. These accommodations might include but are not
limited to special equipment, changes in the physical layout of your office etc.:
__________________________________________________________________________
5. Identify and describe any special methods or procedures that would enable you to perform
the essential functions of your position: __________________________________________
6. Identify and describe any equipment, aids, or services that you are willing to provide:
__________________________________________________________________________
7. Provide the names and addresses of any physicians, therapists, psychologists, or other
licensed health care providers who have information or documentation concerning your
© Copyright 2012 Docstoc Inc. 2
impairment as it affects your need for accommodation by Company:
_____________________________________________________________________. If
none, please explain why you have not obtained an evaluation or treatment.
________________________________________________________________________
8. Have any health care providers advised you not to perform any part of your current job? If
yes, please provide details. ___________________________________________________
9. Please provide any other information you think would be helpful in reviewing your request:
_________________________________________________________________________
PLEASE READ THE FOLLOWING CAREFULLY, THEN SIGN AND DATE
I have a disability that I believe has, or may have, an adverse effect on my work performance. In
order to minimize or eliminate the effect of the disability on my work performance, I am
voluntarily requesting that Company review my situation for the purpose of considering a
reasonable accommodation. I understand that submitting this form is an initial step only. I
understand that Company will not assume, based on my submission of this form, that I am
disabled or that a change or accommodation in the workplace is required. I understand that
Company must be able to confirm the existence and extent of the disability and how it may relate
to the duties and responsibilities of the position involved. I understand that this information is
necessary so that Company can respond to this request, and that this form and any attachments I
have provided may be shared with the health care providers I have identified, as well as with
other health care providers with whom Company may consult in evaluating this request. I also
understand that appropriate consideration of this request may require disclosure of information
about my impairment to supervisors and others at Company who may have a need to know
enough about the impairment to participate effectively in discussions about possible
accommodations, and/or in implementing accommodations. I agree to provide any other
information needed in order to respond to this request. I hereby authorize the above listed
health care providers and any others who have treated me to release to Company all medical
records concerning the impairment disclosed herein as it may affect my ability to perform the job
in question, and to provide any opinions to Company concerning my ability to perform job-
related functions with or without reasonable accommodation. I certify that I have read and
reviewed the job description for my position, and/or have been informed of what the Company
considers the essential functions of this position. I further certify that the foregoing statements
are complete, accurate, and true to the best of my knowledge. I also understand that Company
may require me to undergo testing or evaluation by medical personnel retained by the Company
for the purpose of establishing the existence and extent of my disability, and my ability to
perform job-related functions with or without reasonable accommodations.
SIGNATURE OF EMPLOYEE: ______________________________________
DATE: ______________________
DEFINITIONS: [Comment: These definitions are meant as a guide. Company may wish to
verify state statute does not define these words or phrases in an alternate manner which
may provide additional rights to the requester.]
Disability: a physical or mental impairment that substantially limits one or more major life
activities.
Major life activities include such things as caring for oneself, performing manual tasks, walking,
sitting, standing, lifting, reaching, seeing, hearing, breathing, learning and working.
© Copyright 2012 Docstoc Inc. 3
Reasonable accommodation: any reasonable modification to the job or work environment to
enable a qualified individual with a disability to perform the essential functions of the job.
© Copyright 2012 Docstoc Inc. 4