HR RA Document Form

HR RA Document Form

Employee Information

Full legal name:

Position Information

Date employment began:

Employment status: Full-time Part-time Temporary Contractor

Reasonable Accommodation Request

Date of request:

Desired timing/duration: Temporary Permanent If temporary, expected duration:

Common accommodation options (select all that apply): Modified schedule or breaks Remote or hybrid work Reassignment to vacant position Physical workplace modification Assistive technology or equipment Other (describe below)

Medical Documentation and Releases

Do you have supporting medical documentation? Yes No

I authorize the employer to request or discuss relevant medical information with my health care provider to evaluate this accommodation request: I authorize

Interactive Process and Confidentiality

Upon receipt of this form, the employer will engage in an individualized interactive process to determine reasonable accommodations. The employer may request additional documentation where appropriate. The interactive process is intended to identify effective accommodations that enable performance of essential functions while preserving workplace safety, unless doing so would create an undue hardship.

Medical information obtained in connection with this request will be maintained separately from the employee's personnel file and disclosed only to supervisors and managers on a need-to-know basis, or as required by law. The employer prohibits retaliation for requesting an accommodation or participating in the interactive process.

Employment History (Most Recent Employers)

Education

Graduation or completion date:

References (Professional)

Legal Disclosures

At-Will Employment: If you are an employee employed at will, nothing in this form or any accommodation decision shall alter the at-will nature of employment. The employer retains the right to terminate the employment relationship at any time, for any lawful reason, with or without notice unless otherwise governed by a written agreement signed by authorized representatives.

Equal Employment Opportunity: The employer complies with applicable laws prohibiting discrimination and will consider reasonable accommodations for qualified individuals with disabilities. Requests will be evaluated on an individualized basis.

Non-Retaliation: The employer prohibits retaliation against any individual for requesting an accommodation, assisting in a request, or participating in the interactive process. If you believe you have been subjected to retaliation, you should promptly notify Human Resources.

Authorization to Contact Previous Employers and Background Checks

By checking the box below, I authorize the employer to contact the previous employers listed on this form and to conduct background checks, reference checks, and other verifications as necessary to evaluate my employment history and accommodation request.

I authorize contact with prior employers for verification and reference purposes.

I consent to background checks and verifications in connection with this request and my employment.

Applicant Certification

I certify under penalty of perjury that the information I have provided on this form is true, complete, and correct to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action, up to and including termination of employment. I understand that submission of this form initiates the employer's review and interactive process and does not itself guarantee that the requested accommodation will be granted.

I acknowledge that I have read and understood the confidentiality, non-retaliation, and authorization provisions contained in this form.

Employer Use Only

Date received:

HR determination: Approved Denied Modified

Sign Now