Is notarization required for this request?

No. Accommodation request forms are internal HR records and typically do not require notarization. Only use notarization if specifically required by local policy or to authenticate a separate legal instrument.

Can I attach medical records securely?

Yes. Share medical documentation only through secure channels that limit access to authorized HR staff. Use signed releases to allow providers to share relevant functional information only.

Is an electronic signature valid on this form?

Yes. Electronic signatures meet the ESIGN Act and UETA requirements when they demonstrate intent, consent, attribution, and record retention. Maintain an audit trail for verification.

Who decides whether to grant an accommodation?

The employer, through HR and the supervisor, makes the decision after the interactive process, considering effectiveness, undue hardship, and supporting documentation.

What if the request is denied?

Document the reasons, any alternative accommodations offered, and the interactive-process steps taken. Employees can seek internal appeals or file a charge with the EEOC or equivalent state agency.

How long should records be kept?

Retain active records while accommodation is in effect and keep documentation after termination for at least three years; retain medical records per HIPAA when applicable.

Electronic Signature
Templates
HR
Employee Reasonable Accommodation Request

Employee Reasonable Accommodation Request

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

EMPLOYEE REASONABLE ACCOMMODATION REQUEST

Purpose: Use this form to request a reasonable accommodation to perform the essential functions of your job due to a medical condition, disability, or other limitation. Complete all applicable sections, sign where indicated, and provide any supporting documentation. The information provided will be used to evaluate the request and will be kept confidential to the extent permitted by law.

Personal Information

Full legal name Address

Phone:

Email:

Position Information

Job title Department

Reporting manager:

Employment start date:

Current compensation (annual or hourly)

Accommodation Request Details

Date of request:

Type(s) of accommodation requested (select all that apply):

Schedule modification (part-time, flexible hours) Leave of absence or intermittent leave Physical worksite modification (desk, ramp, restroom) Assistive device or assistive technology Job restructuring or reassignment Telecommuting / remote work Other (describe below)

If other, please describe Describe the medical condition, disability, or limitation that necessitates the accommodation Describe the specific accommodation(s) you are requesting and how it will assist you in performing essential job functions Expected duration of accommodation

Preferred effective date:

Have you previously received accommodations for this condition at this employer?

Yes No

If yes, describe prior accommodations and outcome How do the limitations affect your ability to perform the essential functions of your job?

Medical Documentation and Release

Will you provide medical documentation to support this request? Yes No

If yes, medical provider name and contact

By checking the box below and signing this form, I authorize the employer and its designated representatives to communicate with my health care provider(s) and to request and review medical information reasonably necessary to evaluate this accommodation request, subject to confidentiality protections. This authorization is limited to information necessary to establish the existence of a condition that affects major life activities, functional limitations relevant to job performance, and recommended accommodations.

I authorize release of medical information as described above

Alternative or Interim Accommodations

If the requested accommodation is not feasible, describe alternative accommodations you would consider

Employment History (previous employers)

Employer 1

Company name Job title

Dates employed (from):

(to):

Primary responsibilities Reason for leaving

Employer 2

Company name Job title

Dates employed (from):

(to):

Primary responsibilities Reason for leaving

Education

Highest degree or certification Institution

Graduation date:

References (professional)

Reference 1 — Name

Phone:

Email:

Relationship Reference 2 — Name

Phone:

Email:

Relationship Reference 3 — Name

Phone:

Email:

Relationship

Legal Disclosures and Statements

At-will employment: Receipt and consideration of this request does not alter the at-will employment relationship, unless expressly set forth in a separate written agreement signed by duly authorized representatives of the employer.

Equal opportunity and nondiscrimination: The employer provides reasonable accommodations in accordance with applicable laws and company policy. Requests will be evaluated on an individualized basis. Retaliation against an individual for requesting an accommodation is prohibited.

Confidentiality: Information about medical conditions, medical records, and health information will be maintained separately from personnel files and disclosed only to those involved in the interactive process and in accordance with applicable confidentiality requirements.

Authorization to contact previous employers and conduct background checks: I understand that the employer may contact previous employers and may conduct routine background or employment verification checks to the extent permitted by law and relevant to the assessment of this request. By checking the box below I authorize such verifications.

I authorize the employer to contact previous employers and obtain employment verification/background information as needed to evaluate my request

Applicant Certification

I certify that the information provided in this form is true, accurate and complete to the best of my knowledge. I understand that knowingly providing false or misleading information in order to obtain an accommodation may result in disciplinary action. I agree to cooperate in the interactive process, which may include providing reasonable additional documentation and participating in meetings with human resources and management to identify effective accommodations.

I certify that the information provided above is true and complete and I agree to cooperate in the interactive process

Employee Name:

Signature:

Date:

What an Employee Reasonable Accommodation Request Does

An Employee Reasonable Accommodation Request is a written form employees use to ask an employer for a change or adjustment at work because of a disability or medical need. The document records the employee's contact details, the accommodation requested, relevant medical information or documentation, and whether an accommodation would enable performance of essential job functions. It begins the interactive process between the employee and employer under federal disability laws and creates a record used for decisions, tracking, and privacy-protected storage.

Why this Request Matters for Compliance and Recordkeeping

Using a standard request form helps employers document the interactive process, evaluate accommodations consistently, and protect employee privacy under applicable laws.

Who completes and relies on this form

The form is completed by the employee and used by HR, managers, and designated accommodation coordinators to evaluate and implement adjustments.

Employee — Submits personal details, describes functional limitations and accommodation preference; documents the requested change.
HR / ADA Coordinator — Receives requests, conducts the interactive process, documents assessments and decisions.
Healthcare Provider or Disability Specialist — Supplies medical information or functional limitations when requested and authorized.

The form creates a centralized, confidential record used throughout the accommodation evaluation and any subsequent follow-up.

Core components that belong on a professional request form

A concise, well-structured form promotes accurate intake and consistent decision-making. Include items that support the interactive process while protecting privacy.

Employee Details

Full legal name, job title, department, contact information and supervisor name to ensure the request is routed to the correct reviewer.

Accommodation Requested

Clear description of the physical, scheduling, or equipment change being requested and the employee's stated preferred solution or alternatives.

Functional Limitations

Description of how the disability or medical condition limits specific job tasks or workplace access; focus on function, not diagnosis.

Medical Documentation

Space to note supporting documentation and a checklist for signed releases so providers may share only necessary information with HR.

Essential Job Functions

Reference to the specific job duties relevant to the request so evaluators can match accommodations to job requirements.

Interactive Process Notes

Section for employer responses, alternative proposals, implementation steps, deadlines, and signatures to document decisions and timelines.

Required data elements on the form

Employee name: Full legal name

Contact info: Phone and email

Job title: Current position

Accommodation: Requested change

Medical docs: Documentation present?

Decision log: Outcome and dates

Step-by-step submission process

Follow these four steps to submit a complete request and keep communication clear during the interactive process.

01

Complete form: Fill all required fields and attach any supporting documentation.
02

Submit to HR: Send via your employer's designated channel or deliver to the ADA coordinator.
03

Interactive process: HR and employee discuss reasonable options and request clarifications if needed.
04

Document decision: Record agreed accommodations, implementation dates, and any periodic reviews.

Configuring an online accommodation workflow

Recommended settings for digital intake forms and approval routing to streamline review and maintain an audit trail.

Field	Configuration
Intake fields	Require name, job, limitation, requested accommodation
Attachments	Allow secure uploads; limit file types to PDF and DOCX
Routing	Auto-route to HR and accommodation coordinator
Notifications	Email alerts for new requests and pending actions

Where to file and how requests move through the organization

Clear routing reduces processing time and preserves confidentiality. Typical paths are listed below.

Employee submits: Via secure HR portal or email to ADA coordinator
HR intake: HR reviews completeness and logs request
Interactive meeting: Discuss options, request medical clarification if needed
Implementation: Approve, schedule, and track completion

Digital delivery and eSubmission considerations

Use a secure platform that supports encrypted uploads, role-based access, and audit trails to protect sensitive medical data.

File types: PDF, DOCX
Integrations: HRIS, Microsoft 365, Google Workspace
Security: TLS in transit; AES-256 at rest

Ensure the platform can produce an auditable record, restrict access to medical information, and meet any required privacy or BAA terms.

Common mistakes to avoid when preparing a request

Providing diagnosis instead of functional limitations, which can lead to unnecessary privacy disclosures and evaluation delays.
Failing to include contact information or job details, causing routing delays and incomplete assessments.
Submitting unsupported or overly broad accommodation requests without suggested alternatives or documentation.
Not documenting employer communications or decisions, which complicates compliance reviews and potential disputes.

Risks and potential consequences of mishandled requests

Discrimination Claim: EEOC charge or lawsuit risk

Regulatory Exposure: Administrative penalties or investigator findings

HIPAA Breach: Fines and remediation if PHI improperly disclosed

Operational Delay: Productivity loss from unresolved accommodations

Reputation: Employee trust and public perception damage

Legal Costs: Attorney fees for defense or settlement

Timing expectations and internal service levels

There are no uniform federal deadlines for responding to an accommodation request, so employers should establish clear internal timelines.

Acknowledge Receipt:

Within 3 business days of receiving the request

Request Clarification:

Ask for necessary medical clarification promptly to avoid delays

Initiate Interactive Process:

Begin discussions as soon as practical after intake

Implement or Deny:

Communicate final decision and timelines within a reasonable period

Review Schedule:

Set follow-up to review accommodation effectiveness periodically

Practical examples of common accommodation scenarios

These anonymized scenarios show how form-based requests inform decisions and documentation in everyday situations.

Office Worker with Mobility Needs

An employee requests an accessible workstation and modified break schedule to manage fatigue

HR requests limited medical clarification
The employer documents approval, delivery timeline, and periodic review schedule to measure effectiveness and make further adjustments as needed.

Teacher Needing Reduced Lift Duties

A classroom teacher requests relief from heavy lifting due to a medical condition

School requests functional job analysis
The school assigns assistance for transfers, documents the accommodation, and schedules an end-of-term effectiveness review with HR.

eSignature vendor comparison for processing accommodation requests

Basic pricing and feature contrasts for common eSignature vendors. signNow is listed first per platform comparison guidance.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no credit card required	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently asked questions about accommodation requests

Answers to common concerns about format, signatures, medical privacy, and next steps during the interactive process.

Need help? Contact support

Is notarization required for this request?
No. Accommodation request forms are internal HR records and typically do not require notarization. Only use notarization if specifically required by local policy or to authenticate a separate legal instrument.
Can I attach medical records securely?
Yes. Share medical documentation only through secure channels that limit access to authorized HR staff. Use signed releases to allow providers to share relevant functional information only.
Is an electronic signature valid on this form?
Yes. Electronic signatures meet the ESIGN Act and UETA requirements when they demonstrate intent, consent, attribution, and record retention. Maintain an audit trail for verification.
Who decides whether to grant an accommodation?
The employer, through HR and the supervisor, makes the decision after the interactive process, considering effectiveness, undue hardship, and supporting documentation.
What if the request is denied?
Document the reasons, any alternative accommodations offered, and the interactive-process steps taken. Employees can seek internal appeals or file a charge with the EEOC or equivalent state agency.
How long should records be kept?
Retain active records while accommodation is in effect and keep documentation after termination for at least three years; retain medical records per HIPAA when applicable.

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