Can this form be signed electronically?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and record retention requirements are met.

Do I need a BAA for medical info?

If the form contains protected health information, use a vendor that will execute a Business Associate Agreement to meet HIPAA obligations and safeguard PHI.

What if an employee refuses to complete the form?

Document the request, attempts to obtain information, and the interactive steps taken; lack of cooperation may limit accommodation options but does not relieve the employer of good‑faith duties.

How should we protect medical attachments?

Store medical documentation separately from general personnel files, restrict access to authorized reviewers, and use encryption in transit and at rest.

Who reviews disputed accommodation denials?

Escalate to HR leadership and legal counsel for high‑risk or contested denials; maintain all documentation of the interactive process for review.

Can state laws change form requirements?

Yes. State privacy and execution rules vary; consult state counsel for unique local requirements affecting processing, retention, or disclosure.

Electronic Signature
Templates
HR
HR ADA Survey Form

HR ADA Survey Form

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

HR ADA SURVEY FORM

Purpose: This form is used to request assessment for reasonable accommodation under the Americans with Disabilities Act (ADA) and related laws. Completion of this form initiates the employer's interactive process to evaluate potential workplace accommodations. Responses will be treated as confidential medical information and disclosed only as necessary to evaluate the request.

Personal Information

Full legal name:

Employee ID Home address

Phone

Email

Preferred contact method (select all that apply)

Phone Email Mail In person

Position Information

Job title:

Department Supervisor / Manager

Work location:

Date employed in current position:

Employment History (most recent first)

Employer 1 — Company

Responsibilities Reason for leaving Employer 2 — Company

Responsibilities Reason for leaving

Education

Highest degree or certification Institution Graduation or completion date

References

Reference 1 Reference 2 Reference 3

Equal Opportunity & At-Will Statement

Equal Opportunity: The employer provides equal employment opportunities and does not discriminate on the basis of disability. Reasonable accommodations will be considered in accordance with applicable law.

At-Will Employment: Nothing in this form alters the at-will employment relationship where applicable. Submission of an accommodation request does not guarantee continued employment or modify the terms of employment.

Disability and Accommodation Information

Do you identify as an individual with a disability or a condition that substantially limits one or more major life activities? Yes No

If yes or if you choose to describe, briefly describe the functional limitations relevant to your job

Do these limitations affect your ability to perform any essential functions of your job? Yes No

If yes, list the essential functions impacted and describe the limitation for each Describe the specific accommodation(s) you are requesting

Is this accommodation temporary or permanent? Temporary Permanent

Proposed start date for accommodation: Estimated duration or review date:

Have you previously received this or other workplace accommodations from this employer?

Yes No

If yes, describe prior accommodation(s) and outcome Assistive devices, equipment, or technology you use or propose to use

Medical Documentation & Provider Contact

Do you have medical documentation to support this request? Yes No

If yes, indicate whether documentation is attached or will be provided Health care provider (name)

I authorize the employer and its designated representatives to obtain or verify medical information necessary to evaluate this accommodation request. This authorization is limited to information necessary to determine functional limitations, need for accommodation, and proposed duration. I authorize

Confidentiality, Interactive Process, and Certification

Confidentiality: Medical and disability-related information provided on this form will be maintained separately from general personnel files and disclosed only to those with a need to know as part of the interactive process or to comply with law. Information will be retained only as long as necessary.

Interactive Process: Upon receipt of this form, the employer will engage in a timely, good-faith interactive process to identify potential reasonable accommodations. The employer may request additional information, propose alternative accommodations, or seek medical clarification where appropriate.

No Guarantee: Submission of this request is not a guarantee that the requested accommodation will be granted. The employer will consider reasonableness, effectiveness, and undue hardship in making a final determination consistent with applicable law.

Certification: I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action. I agree to cooperate in the interactive process and to provide additional information or documentation as reasonably requested.

Additional comments

Printed Name:

Signature:

Date:

What the HR ADA Survey Form Is and Why It Matters

The HR ADA Survey Form is an internal human resources document used to assess an employee's need for a workplace accommodation under the Americans with Disabilities Act. It collects factual information about functional limitations, job duties, accommodation preferences, and supporting documentation while protecting confidentiality. HR uses the form to document the interactive process, evaluate reasonable accommodations, and record decisions, timelines, and follow-up. Accurate completion creates an audit-ready record for compliance with federal law and supports consistent, nondiscriminatory handling of accommodation requests across the employer.

Why Use a Standardized ADA Survey Form

A standardized HR ADA Survey Form promotes consistent decision-making, documents the interactive process, and reduces legal risk. It helps HR capture necessary facts, limits ad hoc accommodation practices, and creates a reusable record for audits, requests, and future reviews.

Roles That Typically Complete or Review This Form

HR, managers, EEO officers, and disability coordinators use this form to collect accommodation details, document the interactive process, and track pending requests.

Human resources teams managing accommodation requests, internal policies, interactive process records, and compliance audits.
Supervisors documenting job duties and assessing essential functions for accommodation fit.
Occupational health or disability case managers collecting medical details and return-to-work restrictions.

Assign role-based access so only authorized staff see medical details; keep the form in restricted employee records for confidentiality and compliance.

Key Signatories and Their Responsibilities

EEO Coordinator

Responsible for intake and tracking of ADA accommodation requests, facilitating the interactive process, and coordinating assessments. They document determinations, recommend reasonable accommodations, and maintain confidential records in accordance with federal law and organizational policy.

HR Director

Oversees compliance programs, approves accommodation budgets, and signs formal notices. They ensure consistent application of the HR ADA Survey Form, review legal risk, and authorize escalation to legal counsel or occupational health when requests implicate performance or safety concerns.

Essential Parts of a Professional HR ADA Survey Form

A complete HR ADA Survey Form captures employee details, job information, functional limitations, accommodation requests, medical documentation references, and outcome records so HR can document the interactive process clearly and defensibly.

Employee Details

Name, employee ID, contact, department, and job title for accurate identification and recordkeeping.

Job Duties

Concise description of essential functions to assess accommodation impact and performability.

Functional Limitations

Specific work-related limitations described in objective terms, not diagnoses, to focus on job effects.

Accommodation Requested

Employee's preferred accommodation, alternatives, and any temporary or permanent preference noted.

Medical Documentation

Reference dates and provider contact; limit details to what is job-related and necessary.

Outcome & Follow-up

Decision, effective date, reviewer names, review schedule, and any monitoring or reassessment plan.

Step-by-Step: Completing the HR ADA Survey Form

Follow these steps to complete the HR ADA Survey Form accurately, preserve confidentiality, and create an audit-ready record of the interactive accommodation process.

01

Gather Info: Collect the employee statement, job description, and any supporting medical documentation before assessment.
02

Assess Limitations: Compare reported limitations against essential functions and identify barriers to performance or safety.
03

Propose Options: List potential reasonable accommodations, feasibility notes, costs, and timelines for implementation.
04

Document Decision: Record the agreed accommodation, decision rationale, reviewer names, and scheduled reassessment date.

How to Configure an Online Workflow for the Form

Configure fields, conditional logic, and routing so the form captures only relevant information and automatically moves through review stages.

Field	Configuration
Employee Info	Required fields; HR access; read-only after filing
Medical Info	Encrypted; restricted to authorized reviewers
Accommodation Options	Conditional list shown when limitations are indicated
Reviewer Routing	Auto-route HR -> Occupational Health -> Legal

Technical and Security Considerations for eSubmission

Identify technical and security requirements before eSubmission to ensure HIPAA compliance, appropriate access controls, and audit logging.

Formats: PDF and DOCX supported
Integrations: HRIS, document storage, and SSO
Authentication: Email link, SMS code, or MFA

Where to Send the Completed HR ADA Survey Form

After completion, route the HR ADA Survey Form to the designated HR or disability contact, upload a confidential copy to secure records, and notify relevant reviewers in the interactive process.

HR Records: Upload to secure HR file with restricted access
Disability Office: Send to accommodation coordinator for review
Occupational Health: Provide medical documentation through protected channels
Legal Counsel: Escalate ambiguous or high-risk cases for review

Recommended Timelines and Internal Deadlines

Create internal deadlines to keep the interactive process timely. The ADA requires a good-faith, prompt response but does not set a fixed federal deadline; use consistent internal targets.

Request Acknowledgement:

Acknowledge receipt within 3 business days

Initial Assessment:

Complete initial review within 10 business days

Medical Documentation:

Request additional medical info within 7 business days

Decision Window:

Provide accommodation determination within 15 business days of complete information

Review Cycle:

Schedule follow-up review within six months or sooner

Common Mistakes to Avoid When Preparing the Form

Over-sharing clinical details in the main form rather than attaching redacted provider statements breaches confidentiality and increases legal risk under privacy rules.
Failing to engage the employee in the interactive process and treating the form as one-way intake can create evidence of noncompliance and missed solutions.
Vague accommodation descriptions such as 'reasonable adjustments' without specifics lead to implementation delays and inconsistent enforcement across supervisors.
Missing signatures, dates, or reviewer names weakens the record and complicates audits, appeals, or post‑decision reviews by internal or external investigators.

Penalties and Risks of Incomplete or Incorrect Forms

ADA Liability: Possible compensatory damages and back pay

Privacy Breach: Fines and reputational harm

Retaliation Claim: Separate legal exposure for adverse actions

Inadequate Records: Difficulty defending decisions in audits

Delayed Accommodation: Productivity loss and increased risk

Regulatory Scrutiny: EEOC or state agency investigation potential

Examples: How Organizations Use the HR ADA Survey Form

These anonymized scenarios show practical outcomes when an ADA-focused intake form is used consistently across teams and locations.

Healthcare System

A regional hospital used the HR ADA Survey Form to centralize requests across departments and shifts.

Reduced processing time by about 50 percent.
Standardized intake allowed occupational health to coordinate timely evaluations, documented decisions for auditors, and reduced repeated documentation requests from employees and providers, improving consistency and responsiveness.

Construction Contractor

A mid-size contractor adopted the form for field employees to report functional limits and equipment needs.

Enabled faster on-site adjustments within 10 days.
Implementation increased supervisor clarity on essential duties, limited safety risks by documenting temporary restrictions, and provided a defensible record for worker accommodations during peak projects.

Practical Tips for Accurate and Efficient Completion

Apply these practices to reduce errors, protect privacy, and speed resolution of accommodation requests.

Use Clear Language

Describe limitations and duties in plain terms and avoid medical diagnoses in the main intake form.

Limit Disclosure

Share medical details only with authorized reviewers and attach documentation under restricted access.

Set Internal SLAs

Publish acknowledgement and decision timelines so employees and managers know when to expect outcomes.

Keep Audit Trail

Record dates, reviewers, and rationale for decisions to support future reviews or claims.

FAQs and Troubleshooting for the HR ADA Survey Form

Answers to common operational, legal, and technical questions that arise when using the HR ADA Survey Form.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and record retention requirements are met.
Do I need a BAA for medical info?
If the form contains protected health information, use a vendor that will execute a Business Associate Agreement to meet HIPAA obligations and safeguard PHI.
What if an employee refuses to complete the form?
Document the request, attempts to obtain information, and the interactive steps taken; lack of cooperation may limit accommodation options but does not relieve the employer of good‑faith duties.
How should we protect medical attachments?
Store medical documentation separately from general personnel files, restrict access to authorized reviewers, and use encryption in transit and at rest.
Who reviews disputed accommodation denials?
Escalate to HR leadership and legal counsel for high‑risk or contested denials; maintain all documentation of the interactive process for review.
Can state laws change form requirements?
Yes. State privacy and execution rules vary; consult state counsel for unique local requirements affecting processing, retention, or disclosure.

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