HR CARES Form

HR CARES Form

Purpose: Use this HR CARES Form to report workplace concerns, request assistance or accommodations, document incidents affecting employee wellbeing, and authorize HR to take appropriate actions. Complete all applicable sections. Fields marked below request information necessary to evaluate needs and maintain appropriate confidentiality.

Personal Information

Employee ID:    Phone:    Email:

Emergency Contact

Relationship:    Phone:

Position Information

Department:    Reporting manager:    Manager contact:

Start date with organization:    Employment status:

Employment History (Most recent two employers)

Title:    Start:    End:

Title:    Start:    End:

Education

Graduation date:

References (Professional)

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

CARES Assessment — Type of Assistance Requested

Crisis intervention or immediate safety assistance
Medical leave or extended absence
Emotional support / counseling referral
Workplace accommodation / adjustment request
Safety or harassment concern
Referral to employee assistance program (EAP)
Other (please describe below)

Incident / Concern Details

Request for Accommodation or Support

I request the following accommodation/support (check all that apply):
Temporary schedule change
Workstation or equipment adjustment
Remote work / telecommuting
Light duty assignment
Direct referral to counseling or EAP
Other (please describe below)

Confidentiality, Release, and Authorization

The information provided will be used by HR and appropriate organizational representatives to assess needs and implement support measures. The organization will share information on a need-to-know basis consistent with applicable law and organizational policy. By signing below, the employee authorizes the organization to contact listed references and prior employers as necessary to verify employment history and to conduct any background checks required by policy when such checks are relevant to requested accommodations or safety concerns.

I authorize HR to contact prior employers and references for employment verification and relevant background information.
I authorize HR to share necessary information with my reporting manager for the purposes of implementing accommodations or safety measures.
I consent to referral to the employee assistance program (EAP) or other support providers as recommended.

Legal Notices and Disclosures

At-Will Employment: Nothing in this form or any accommodation or action taken as a result of this form alters the at-will employment relationship between the employee and the organization, unless a separate, signed written agreement states otherwise.

Equal Opportunity: The organization is an equal opportunity employer. Requests for assistance, reporting of incidents, and accommodations will be handled without unlawful discrimination. Retaliation against an individual for requesting assistance or reporting a concern in good faith is prohibited.

Applicant / Employee Certification: I certify that the information provided in this HR CARES Form is true, accurate, and complete to the best of my knowledge. I understand that intentionally providing false information may result in administrative action. I further acknowledge that HR may need to disclose information to other internal parties as necessary to address the issue.

I acknowledge and certify the statements above.

HR Use Only

Assessment date:    Recommended action (check if applicable):
No further action required
Implement accommodation
Refer to EAP/counseling
Formal investigation recommended

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