Workplace Reasonable Accommodation Request Form

WORKPLACE REASONABLE ACCOMMODATION REQUEST FORM

Use this form to request a workplace reasonable accommodation. Completion of this form initiates the employer's interactive process to evaluate and, where appropriate, provide reasonable accommodation in accordance with applicable law and the employer's accommodation policy.

WHEREAS

WHEREAS Employer Name: maintains responsibilities under applicable disability and employment laws to consider requests for reasonable accommodation; and

WHEREAS Employee Name: seeks a reasonable accommodation to perform the essential functions of Employee Job Title: with respect to a medical condition or limitation; and

WHEREAS the parties intend to engage in an interactive process to identify effective reasonable accommodations consistent with the requirements of law and the operational needs of the workplace.

EMPLOYEE INFORMATION

NATURE OF CONDITION

Briefly describe the medical condition, impairment, or limitation that necessitates the accommodation. Include how the condition limits the employee's ability to perform essential job functions.

ACCOMMODATION REQUEST

Please indicate the accommodation(s) requested. Check all that apply and provide relevant details or alternatives.

MEDICAL OR SUPPORTING INFORMATION

If medical or other supporting documentation is necessary to evaluate this request, provide details below or attach documentation to this form. The employer will maintain the confidentiality of medical information as required by law.

COSTS, REIMBURSEMENT, AND ADMINISTRATIVE TERMS

Costs for certain accommodations may be shared or reimbursed consistent with employer policy. Complete the fields below only if the accommodation involves a financial arrangement or reimbursement agreement.

If reimbursement is agreed and a payment schedule is missed, a reasonable administrative late fee may apply as permitted by policy and law. Any such amount shall be documented in writing.

TERM, WITHDRAWAL, AND TERMINATION

Accommodation Start Date:   Expected End Date (if temporary):

Either party may request a modification or withdrawal of the accommodation. Employer may modify or discontinue an accommodation where doing so is consistent with applicable law, reasonable business necessity, or if the accommodation imposes an undue hardship, provided Employer first notifies Employee in writing and, where appropriate, proposes alternative accommodations.

CONFIDENTIALITY

All medical information and documentation provided in connection with this request will be treated as confidential medical records and will be maintained separately from general personnel files, disclosed only to those with a need to know to evaluate or implement the accommodation, and as otherwise required by law.

EMPLOYER DETERMINATION / INTERACTIVE PROCESS (FOR HR USE)

Date Received by HR:

GOVERNING LAW AND ENTIRE AGREEMENT

This request and any written accommodation agreement that may be executed pursuant to this request shall be governed by the laws applicable to the employer's operations, and to the extent required by law, shall be construed consistent with applicable federal, state, and local statutes and regulations governing disability accommodations. This form, together with any written accommodation agreement signed by the parties, constitutes the complete understanding between the parties with respect to the subject matter and supersedes any prior oral or written communications regarding the same.

EMPLOYEE CERTIFICATION

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that I may be required to provide reasonable documentation to support this request and that failure to provide such documentation may delay or affect the employer's ability to evaluate the request.

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