What is the form used for?

The form documents an employee's request for a workplace accommodation under the ADA, captures needed facts, and triggers the employer's interactive process to evaluate reasonable accommodations.

Who must complete the form?

The employee or authorized representative should complete the form; HR or a supervisor may assist, but the employee's signature or consent should be recorded to show intent.

Can the form be signed electronically?

Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.

What supporting documents are typical?

Relevant medical notes or functional assessments focused on limitations and need for accommodation are typical; request only information necessary to evaluate the accommodation.

How long does processing take?

Timing depends on documentation and complexity; employers should promptly engage in the interactive process and document all communications to demonstrate good faith.

How can an employee withdraw a request?

An employee may withdraw in writing; record the withdrawal and retain the form per retention policy. Ensure the record shows the withdrawal date and the party who accepted it.

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Templates
HR
HR ADA Accommodation Request Form

HR ADA Accommodation Request Form

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

HR ADA ACCOMMODATION REQUEST FORM

This form is used to request reasonable accommodation under the Americans with Disabilities Act (ADA) and applicable local law. Complete all applicable sections. Information provided is confidential and will be used to evaluate your request and engage in the interactive process with you and, if necessary, with your medical provider and supervising managers.

Personal Information

Employee Full Name Employee ID Home Address

Phone:

Email:

Position Information

Department Job Title

Reporting Manager:

Work Location:

Employment Status: Full-time Part-time Temporary

Hire Date:

Current Salary or Pay Rate

Employment History (Most Recent Two Employers)

Employer 1 - Company Name

Title:

Dates Employed:

Responsibilities Reason for Leaving Employer 2 - Company Name

Title:

Dates Employed:

Responsibilities Reason for Leaving

Education

Highest Degree or Certification Institution Graduation Date

References (Professional)

Reference 1 Reference 2 Reference 3

Accommodation Request Details

Date of this Request:

Nature of Disability or Medical Condition Describe the Work-Related Limitation(s) Accommodation Requested (be specific)

Requested Start Date:

Expected Duration:

Is this accommodation needed immediately? Yes No

Alternative Accommodations Already Considered or Tried

Medical Documentation and Authorization

I have provided or will provide medical documentation to support this request: Attached To follow Not available

Medical Provider / Clinic Name

Authorization to Obtain/Discuss Medical Information: I authorize my health care provider to release to Human Resources and the designated medical reviewer information necessary to evaluate my request for accommodation, limited to diagnosis, functional limitations, and recommended accommodations.

Prior Accommodations and Safety

Have you previously received accommodations from this employer? Yes No

If yes, describe prior accommodations and outcome Are there safety concerns related to this accommodation?

Yes No

If yes, describe potential safety risks and suggested mitigations

Interactive Process and Contact

I understand that the employer may request additional documentation and will engage in an interactive process to determine reasonable accommodations. The company will consider job-related and business necessity factors and may propose alternative accommodations.

Preferred Contact Person (HR or Manager)

Legal Disclosures and Authorizations

At-Will Employment Statement: Submission of this form does not alter the employment relationship. Unless otherwise specified in a written agreement signed by an authorized representative, employment remains at-will and may be terminated by either party at any time.

Equal Opportunity Statement: The employer provides equal employment opportunity and will not discriminate based on disability. Requests for reasonable accommodation will be evaluated in accordance with applicable law and company policy.

Authorization to Verify Information and Contact Previous Employers: I authorize Human Resources to contact my current and former employers, professional references, and medical providers as reasonably necessary to verify information pertinent to this request and to evaluate accommodation options, subject to applicable confidentiality protections.

Applicant Certification: I certify that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action up to and including termination.

Consent: By signing below, I consent to the release of medical information to the employer and any designated medical reviewer for the limited purpose of evaluating the accommodation request, and I consent to participation in the interactive process.

Employer Use Only (Human Resources)

HR Reviewer Determination

Approved Denied Modified/Alternative Provided

Accommodation Implemented (describe)

Implementation Date:

Follow-up Date:

HR Notes

Confidentiality Notice: Medical information obtained in connection with this request will be maintained separately from employee personnel files to the extent required by law and will be disclosed only to those with a legitimate need to know.

Employee Name:

Signature:

Date:

What the HR ADA Accommodation Request Form Is and When it’s Used

The HR ADA Accommodation Request Form is a standardized internal document employees use to request workplace adjustments under the Americans with Disabilities Act. It collects identifying information, a description of the disability or functional limitation, the specific accommodation requested, and any supporting documentation. Employers use the completed form to start the interactive process, document the request, evaluate feasible accommodations, and record the outcome. The form helps ensure consistent intake, supports timely responses, and creates a retention record for compliance and audit purposes.

Why a Clear, Complete Accommodation Request Form Matters

A professional HR ADA Accommodation Request Form standardizes intake, reduces processing delays, and documents the interactive process. Accurate forms support reasonable accommodation assessments, minimize disputes, and preserve records required for regulatory review or litigation.

Who Should Complete or Review This Form

Accurate completion by these parties reduces back-and-forth, speeds resolution, and improves documentation for compliance and record retention.

Employees submitting an accommodation request to document limitations and proposed adjustments in writing.
Human Resources staff responsible for intake, assessing feasibility, and coordinating the interactive process.
Supervisors and managers who evaluate operational impact and help implement approved accommodations.

Step-by-Step: How to Complete the HR ADA Accommodation Request Form

Complete the form in sequence to ensure the interactive process begins without delay and records are stored correctly.

01

Gather Information: Collect job description, physician notes, and payroll ID before starting.
02

Fill Required Fields: Enter personal, job, and accommodation details fully and use MM/DD/YYYY for dates.
03

Attach Evidence: Upload medical documentation or functional assessments as PDFs.
04

Submit to HR: Send through the designated HR channel or eSubmission method for intake and review.

Configuring an Online Workflow for Accommodation Requests

Set up routing, authentication, and storage to preserve audit trails and meet internal retention policies.

Field	Configuration
Routing Order	Employee → HR intake → Manager → HR decision
Authentication	Email link with optional SMS code for added verification
Conditional Fields	Show medical attachment field only if 'Yes' to need verification
Storage Location	Secure HR records repository with restricted access

Delivery Channels and Platform Requirements for eSubmission

Choose platforms that support secure uploads, audit trails, and access controls to protect sensitive health information.

File Formats: PDF or DOCX preferred for form fidelity
Integrations: Connect to HRIS and cloud storage for single-source records
Authentication Options: Email link, SMS code, or stronger methods where needed

Ensure the selected platform supports HIPAA controls if storing protected health information and offers export options for audits.

Typical Processing Flow for an Accommodation Request

A clear workflow improves responsiveness and documents each decision step during the interactive process.

Submission: Employee submits the completed form and attachments
Intake Review: HR confirms receipt and checks for required documentation
Interactive Discussion: HR and employee discuss alternatives and feasibility
Decision & Implementation: HR documents the outcome and implements approved accommodations

Timelines and Recommended Processing Expectations

Federal law does not prescribe a fixed deadline for accommodation responses, but employers should act promptly and document timelines.

Initial Acknowledgment:

Acknowledge receipt within business days per company policy

Interactive Process Start:

Begin interactive communications promptly to gather necessary information

Documentation Follow-Up:

Request additional medical documentation only if necessary and document the need

Decision Timing:

Make a good-faith decision once sufficient information is obtained

Implementation:

Implement agreed accommodations as soon as practicable

Common Pitfalls to Avoid When Preparing the Form

Incomplete employee identifiers or mismatched names cause verification delays and may require re-submission.
Vague accommodation descriptions lead to unnecessary back-and-forth; be specific about equipment, schedule, or modifications.
Requesting unnecessary medical details can violate privacy; limit requests to information needed to assess functional limitations.
Failing to document the interactive process or decision rationale increases litigation risk and weakens compliance defenses.

Essential Data Elements and Security Considerations

Employee Identifier: HRIS ID or payroll number

Contact Details: Work email and phone

Job Details: Title and essential functions

Accommodation Request: Specifics of requested adjustment

Medical Attachments: Redacted to need-to-know information

Access Controls: Limit access to HR and decision-makers

Risks and Legal Consequences of Improper Handling

Discrimination Claim: Potential ADA litigation

Privacy Violation: HIPAA or state privacy exposure

Regulatory Fines: Enforcement actions and penalties

Operational Disruption: Unimplemented accommodations breach retention

Reputational Harm: Employee trust and morale impact

Recordkeeping Gaps: Loss of defense evidence

eSignature Vendor Pricing and Feature Snapshot for Accommodation Forms

Compare baseline plans and common features when selecting an eSignature provider for HR forms. signNow is listed first for parity in comparison.

	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	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

FAQs: Common Questions About the HR ADA Accommodation Request Form

Answers to frequently asked questions about completing, submitting, authenticating, and storing accommodation requests.

Need help? Contact support

What is the form used for?
The form documents an employee's request for a workplace accommodation under the ADA, captures needed facts, and triggers the employer's interactive process to evaluate reasonable accommodations.
Who must complete the form?
The employee or authorized representative should complete the form; HR or a supervisor may assist, but the employee's signature or consent should be recorded to show intent.
Can the form be signed electronically?
Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.
What supporting documents are typical?
Relevant medical notes or functional assessments focused on limitations and need for accommodation are typical; request only information necessary to evaluate the accommodation.
How long does processing take?
Timing depends on documentation and complexity; employers should promptly engage in the interactive process and document all communications to demonstrate good faith.
How can an employee withdraw a request?
An employee may withdraw in writing; record the withdrawal and retain the form per retention policy. Ensure the record shows the withdrawal date and the party who accepted it.

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