Can this form be signed electronically?

Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted if they demonstrate intent, consent, attribution, and retained reproducible records.

Do I need a medical release?

Only include a limited medical-release if necessary to evaluate accommodation needs. When health information is used or disclosed, HIPAA protections and minimum necessary rules apply.

Is a notary or witness required?

Most jurisdictions do not require notarization for an internal authorization, but state or employer policies may require a witness or notary for certain documents or when transferring property.

How long must we keep the signed form?

Retain for the accommodation term plus at least three years; follow HIPAA's six-year rule for health records and any applicable state extensions.

What if the device is lost or damaged?

Document the incident, follow vendor and insurance procedures, and review the original authorization to determine responsibility and next steps.

Can we limit access to the document?

Yes. Store executed forms in secure HR systems, restrict access to authorized personnel, and apply encryption and audit logging to protect confidentiality.

Electronic Signature
Templates
HR
Employee Mobility Aid Authorization

Employee Mobility Aid Authorization

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EMPLOYEE MOBILITY AID AUTHORIZATION

Employee Information

Full Legal Name Home Address

Primary Phone

Email Address

Position Information

Job Title Department Reporting Manager

Hire Date:

Employment History (Most Recent)

Employer 1 — Company Name

Primary Responsibilities Reason for Leaving

Employment History (Previous)

Employer 2 — Company Name

Primary Responsibilities Reason for Leaving

Education

Highest Degree Institution

Graduation Date:

References (Professional)

Reference 1 Reference 2 Reference 3

Mobility Aid Details

Device Ownership: Employee-owned Employer-provided

Device Type

Date Acquired: Expected Return/Renewal Date:

Storage Location at Workplace

Will workplace modifications be required to accommodate the device? Yes No

If yes, describe required modifications

Medical Certification

Employee's medical provider may be contacted for verification of medical necessity. Provide the following:

Medical Provider Name Provider Phone Provider Address Provider Statement (summary of need and any restrictions)

Accommodation Terms and Conditions

The Employer grants limited authorization for the use and/or storage of the specified mobility aid on Employer premises subject to the terms set forth below. This Authorization does not alter the at-will nature of employment where applicable and may be revoked or modified where reasonably necessary for safety, undue hardship, or lack of medical necessity.

Employee responsibilities include but are not limited to: maintaining the device in safe working order; securing the device when not in use; notifying Employer promptly of any defect or safety concern; and complying with training and operational rules required by Employer. Employee shall not make structural alterations to Employer property without prior written approval.

Employer responsibilities include: evaluating reasonable modifications, providing agreed-upon accommodations where feasible, and maintaining confidentiality of medical information to the extent required by law.

Liability: Except for willful misconduct or gross negligence by Employer, Employer is not responsible for damage to employee-owned devices. If Employer provides the device, Employer retains maintenance responsibility unless otherwise agreed in writing.

Maintenance payment responsibility: Employee Employer Shared / As agreed

Privacy, Records, and Authorization

Medical and accommodation records will be maintained separately from general personnel files and accessed only by individuals with a legitimate business need. By signing below, Employee expressly authorizes Employer to contact the listed medical provider and prior employers for verification of need and functional limitations related to this accommodation.

Authorization to contact prior employers and conduct background checks: I authorize Employer to contact prior employers. I authorize Employer to conduct background and safety-related checks as permitted by law.

Legal Disclosures

At-Will Employment: Nothing in this Authorization amends any at-will employment relationship between Employee and Employer, if applicable. Employment may be terminated by either party at any time, with or without cause, subject to applicable law.

Equal Opportunity: Employer provides reasonable accommodations in accordance with applicable law and does not discriminate on the basis of disability. Requests for accommodations are considered on an individualized basis.

Applicant Certification

I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false information may subject me to disciplinary action up to and including termination. I authorize the Employer to obtain verification of the information provided, including contacting prior employers and medical providers as necessary to verify the need for the requested accommodation.

Additional Notes (Employer or HR use)

Employee Name:

By:

Date:

Employer Representative:

By:

Date:

What the Employee Mobility Aid Authorization Is

An Employee Mobility Aid Authorization is a written form that documents an employee's consent for an employer or third party to provide, store, transport, access, or maintain mobility-assistive devices and related accommodations. The form typically records employee and device details, permitted handling or storage instructions, the medical or accommodation basis (if required), and any limited release of medical information. Employers use it to create a clear record of permission, roles, and responsibilities while preserving confidentiality and aligning with accommodation obligations under federal and state law.

Why a Clear Authorization Matters

A signed authorization creates a documented agreement that protects employee privacy, clarifies employer responsibilities, and reduces liability when mobility aids are handled or transported. It helps streamline accommodation decisions and demonstrates compliance with applicable recordkeeping and confidentiality obligations.

Who Typically Completes This Authorization

Keeping a completed form in the employee file documents the accommodation process and supports consistent operational handling while protecting health information where applicable.

Employees requesting or returning mobility aids, or permitting storage or transport by the employer.
HR or disability-accommodation coordinators managing workplace adjustments and recordkeeping.
Facilities, security, or third-party vendors tasked with handling or transporting the equipment.

Essential Elements to Include in the Authorization

A professional Employee Mobility Aid Authorization contains clear identity, device, scope, timeframe, privacy, and signature elements so all parties understand permissions and limits.

Employee Identity

Full legal name, employee ID, job title, and preferred contact details so the authorization ties unambiguously to a specific individual.

Device Description

Make, model, serial number, or distinguishing features of the mobility aid to avoid confusion between items and ensure correct handling.

Scope of Permission

Specify allowed actions (store, transport, repair, use on company premises), named third parties, and any restrictions on access or handling.

Duration and Effective Date

State an effective date and either an explicit end date or renewal terms to define how long the authorization remains valid.

Privacy and Disclosures

Describe any limited medical information release, data handling procedures, and reference HIPAA protections for health-related content when applicable.

Signature and Witness

Employee signature, printed name, date, and signer role; include witness or notary language if required by company policy or state law.

Step-by-Step: Filling and Approving the Authorization

Follow these sequential steps to complete the form, obtain approvals, and record the authorization in HR systems.

01

Step 1: Complete employee identity and device details accurately.
02

Step 2: Specify permitted actions, duration, and any third-party handlers.
03

Step 3: Obtain required signatures and witness or notary if policy demands.
04

Step 4: Store the final executed form in the employee file and update tracking records.

Where to Send and Who Receives the Final Form

Clear routing reduces delays and ensures appropriate custodians maintain the authorization and any related equipment logs.

Human Resources: HR retains the signed copy for accommodation records and personnel files.
Facilities or Security: Facilities receives handling and storage instructions when the employer stores or moves equipment.
Employee: Provide an executed copy to the employee for their records and future reference.
Third-Party Vendor: Send to repair or transport vendors only when the authorization names them explicitly.

How to Configure an Online Authorization Workflow

Set up a repeatable digital workflow to collect, approve, and archive authorizations while maintaining auditability.

Template	Create a reusable template with required fields and conditional sections for medical releases.
Signer Authentication	Require email verification or SMS code to confirm signer identity.
Conditional Fields	Show medical-release fields only when the employee indicates health information disclosure.
Approval Routing	Route signed forms automatically to HR, facilities, and the employee.
Reminders	Enable automated reminder emails for unsigned requests and upcoming expirations.

Distribution and Technical Requirements

Use a platform that retains an auditable certificate of completion and stores executed PDFs in your document repository.

Integrations: Support for HRIS and storage (Salesforce, NetSuite, Google Workspace).
File Formats: Accepts PDF and DOCX for reliable rendering and archival.
Authentication: SMS, email, and advanced signer authentication options.

Typical Processing Times and Internal Deadlines

Expect consistent internal SLAs to avoid operational disruption when mobility aids require handling, storage, or repair.

Employer Review:

Complete internal review within 3–7 business days of receipt.

Device Pickup/Return:

Schedule pickup or return within 5 business days of approval when feasible.

Third-Party Repair:

Vendor repair scheduling typically occurs within 7–14 business days.

Authorization Renewal:

Notify employee 30 days before an authorization expires to renew.

Record Recording:

Store the executed document in HR within 2 business days of signing.

Key Milestones from Request to Closure

Track these milestones to monitor the authorization lifecycle and meet internal deadlines.

01

Request Submitted

Employee completes and submits authorization request online or on paper.

02

Employer Review

HR or facilities evaluates the request and any supporting documentation.

03

Execution

Employee and authorized personnel sign and date the form; witnesses/notary as required.

04

Archive & Action

Store executed form and proceed with storage, transport, or repair actions.

Common Mistakes to Avoid

Incomplete device details: failing to record serial or model numbers leads to confusion and lost equipment.
Overbroad permission language: vague authorizations permit unintended access or transfers and increase liability.
Missing signature validity checks: unsigned or improperly executed forms can be unenforceable or disputed.
Improper handling of medical data: including health information without appropriate safeguards risks HIPAA exposure.

Risks and Legal Consequences of Errors

Privacy Breach: Potential HIPAA liability

Contract Dispute: Unauthorized transfers risk litigation

Administrative Fines: State penalties for improper notary handling

Lost Property: Replacement and reputational costs

ADA Noncompliance: Failure to accommodate claims

Recordkeeping Failures: Evidence gaps on audit or litigation

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HIPAA Compliant	Yes (BAA)	Yes (BAA)	Yes (BAA)	No	No

Frequently Asked Questions

Answers to common practical and legal questions about preparing, signing, and storing an Employee Mobility Aid Authorization.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted if they demonstrate intent, consent, attribution, and retained reproducible records.
Do I need a medical release?
Only include a limited medical-release if necessary to evaluate accommodation needs. When health information is used or disclosed, HIPAA protections and minimum necessary rules apply.
Is a notary or witness required?
Most jurisdictions do not require notarization for an internal authorization, but state or employer policies may require a witness or notary for certain documents or when transferring property.
How long must we keep the signed form?
Retain for the accommodation term plus at least three years; follow HIPAA's six-year rule for health records and any applicable state extensions.
What if the device is lost or damaged?
Document the incident, follow vendor and insurance procedures, and review the original authorization to determine responsibility and next steps.
Can we limit access to the document?
Yes. Store executed forms in secure HR systems, restrict access to authorized personnel, and apply encryption and audit logging to protect confidentiality.

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