HR 504 Plan Template

HR 504 Plan Template

Personal Information

Position Information

504 Accommodation Request

Date of Request:

Documentation Attached: Medical records Physician note Other

Recommended Reasonable Accommodations

Provide specific recommended accommodations, expected duration, implementation responsibilities and estimated cost.

Implementation Timeline and Monitoring

Proposed Implementation Start Date:

Target Completion Date:

Roles and Responsibilities

Employee Responsibilities: Employee agrees to cooperate and communicate regarding accommodation effectiveness and to provide reasonable documentation as requested by Occupational Health or HR.

Supervisor Responsibilities: Supervisor will implement accommodations in good faith, coordinate with HR, and monitor job performance while maintaining confidentiality to the extent practicable.

Costs, Procurement and Funding

Confidentiality and Records

All medical information provided to the employer in connection with this 504 Plan will be maintained separately from general personnel files and disclosed only to those with a legitimate need to implement or evaluate accommodations, except as otherwise required by law.

Legal Considerations and Compliance

This plan is developed consistent with the employer's obligations under Section 504 of the Rehabilitation Act and applicable disability discrimination law. The employer will provide reasonable accommodations unless doing so would impose an undue hardship on operations. The interactive process requires good-faith participation from the employee and employer. Recommendations contained in this plan are not a guarantee of continued accommodation in all circumstances; changes in medical condition, job duties, or undue hardship may require plan modification.

At-Will and Equal Opportunity Statements

At-Will Employment: Nothing in this plan alters the at-will employment relationship between the employer and employee unless otherwise provided in a separate, written agreement signed by authorized representatives of the employer and employee.

Equal Opportunity: The employer is an equal opportunity employer committed to providing reasonable accommodations and prohibiting discrimination on the basis of disability. Retaliation against an individual for requesting or using reasonable accommodation is prohibited.

Employee Certification and Authorization

I certify that the information I have provided in support of this 504 accommodation request is true and complete to the best of my knowledge. I authorize the employer to contact my health care provider or prior employers as necessary to verify information related to job limitations and accommodations. I understand that medical information obtained will be handled in accordance with applicable confidentiality protections.

Employee Consent to Contact Providers: I authorize release of relevant medical information to the employer's designated reviewers for accommodation evaluation.

Employment History (most recent)

Education

Graduation Date:

References (Professional)

Authorization to Contact Previous Employers & Background Checks

I authorize the employer to contact previous employers and references, and to conduct background checks as necessary to verify employment history and fitness for duty with respect to accommodation implementation. This authorization is limited to information relevant to job performance and accommodation evaluation.

Consent to Background Check: Yes

Plan Review and Termination

This plan will be reviewed on the following date or at intervals indicated below. The plan may be amended, suspended or terminated upon written notice if the underlying limitation changes, the essential functions of the position change, or undue hardship is demonstrated by the employer.

Next Review Date:

Employee Acknowledgment

I certify that I have received a copy of this 504 Plan, that I understand the terms and responsibilities described herein, and that I will participate in the interactive process in good faith.

Signature Block

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