One Patient's Positive Perspectives

Sample Reasonable Accommodation Request Form for Employee

A. Questions to clarify accommodation requested.

What specific accommodation are you requesting?
If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore? Yes  ¨ No  ¨
If yes, please explain.
Is your accommodation request time sensitive? Yes  ¨ No  ¨
If yes, please explain.

B. Questions to document the reason for accommodation request.

What, if any, job function are you having difficulty performing?
What, if any, employment benefit are you having difficulty accessing?
What limitation is interfering with your ability to perform your job or access an employment benefit?
Have you had any accommodations in the past for this same limitation? Yes  ¨ No  ¨
If yes, what were they and how effective were they?
If you are requesting a specific accommodation, how will that accommodation assist you?

C. Other.

Please provide any additional information that might be useful in processing your accommodation request:Signature ______________________________Date _______________Return this form to _______________________

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