About this template
A Reasonable Accommodation Request Form is an essential tool for human resources teams and managers to track, evaluate, and process employee requests for workplace modifications. These requests typically stem from a medical condition or disability that impacts an employee's ability to perform standard job functions. By using a standardized intake process, organizations ensure that requests are handled fairly, consistently, and confidentially.
This template collects all critical information needed to review an accommodation request, including the employee's department and job title, a description of the condition or functional limitation, specific accommodation needs, and contact information for the treating healthcare provider. It also includes fields for supporting documentation and formal acknowledgment terms.
Doc2Form allows HR professionals to instantly deploy this form via Google Forms, streamlining internal communications while maintaining a secure and organized digital record of all requests.
Key features
- Collect detailed accommodation requests securely and confidentially
- Gather necessary health care provider contact information
- Include links for supporting medical documentation
- Standardize HR intake for consistency and compliance tracking
- Ready to share instantly using Google Forms
Use cases
Processing workplace adjustments for employees with medical conditions
Managing temporary or permanent physical workspace modifications
Reviewing requests for specialized equipment, ergonomic tools, or mod…
Reviewing requests for specialized equipment, ergonomic tools, or modified schedules
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Phone Number (Short answer)Enter the best phone number to reach you during business hours.
- Email Address (Short answer)Enter your work or primary email address.
- Home Address (Paragraph)Enter your current mailing address.
- Department (Dropdown)Select your current department.
- Job Title (Short answer)Enter your official job title.
- Description of Condition or Limitation (Paragraph)Describe how your medical condition or limitation affects your ability to perform specific job functions.
- Requested Accommodation Needs (Paragraph)Describe the specific accommodation(s) you are requesting (e.g., ergonomic equipment, modified schedule, assistive software).
- Supporting Documentation (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe the document you wish to attach.
- Health Care Provider Name (Short answer)Enter the name of the physician or healthcare professional supporting this request.
- Health Care Provider Phone Number (Short answer)Enter the office phone number for your healthcare provider.
- Terms and Acknowledgment (Multiple choice)Confirm that the information provided is accurate and that you understand HR may contact your healthcare provider if needed.
- Signature (Full Name) (Short answer)Type your full legal name to serve as your electronic signature.
- Submission Date (Date)Select today's date.
FAQ
What is a reasonable accommodation request form?
It is a formal document used by employees to ask their employer for workplace modifications that allow them to perform the essential functions of their job despite a medical condition or disability.
Who should fill out this form?
Employees or job applicants who require a workplace adjustment due to a medical condition, injury, or disability should complete this form to initiate the review process.
Is the information submitted through this form kept confidential?
Yes. HR departments treat medical and accommodation requests as confidential, sharing details only on a strict need-to-know basis with those involved in evaluating the request.
Can employees attach medical documentation?
Yes. The form includes a dedicated section where respondents can provide links to supporting files or describe the medical documentation provided by their healthcare professional.
How can I customize this template?
With Doc2Form, you can instantly generate this form in Google Forms, where you can easily edit questions, add your company branding, and adjust sharing settings.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.