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ADA Accommodation Request Form Template 2024

TL;DR This template guides employees or applicants through requesting accommodations under the Americans with Disabilities Act (ADA) and the Rehabilitation Act, emphasizing the need for clarity, privacy, and ADA compliance in the form's design and process. It outlines the steps for submitting accommodation requests, including providing specific details on the impairment and desired accommodations, and details the Human Resources process for reviewing and implementing these requests while ensuring confidentiality.

Team Disclo
March 26, 2024

This template is designed for employees or applicants to formally request accommodations for disabilities as per the Americans with Disabilities Act (ADA) and the Rehabilitation Act, detailing their specific needs, impairment nature, desired accommodations, and necessary medical documentation (employees only). 

It also outlines the process for Human Resources to review, implement or deny these requests, and ensure confidentiality and adherence to ADA guidelines.

Before we dive in, here are the top 3 tips when it comes to creating or handling an ADA Accommodation Request Form:

Tip #1: Ensure Clarity and Simplicity

  • User-Friendly Design: The form should be straightforward and easy to understand. Use clear language, avoid legal jargon, and ensure the form is accessible for those with visual or cognitive impairments. This might include providing the form in different formats (e.g., large print, Braille, electronically).
  • Specific and Guided Sections: Structure the form with specific sections guiding the employee through the process. This includes clear fields for personal information, detailed accommodation request, the reason for the accommodation, and any supporting medical documentation if required.
  • Instructions and Examples: Provide clear instructions on how to fill out the form and what each section is for. Examples can be helpful, especially in explaining what constitutes a reasonable accommodation and the type of information that mig  ht be useful to include.

Tip #2: Maintain Privacy and Confidentiality

  • Secure Handling of Sensitive Information: The form will contain personal and potentially sensitive medical information. Ensure that the information is handled and stored securely, with access limited to those directly involved in the accommodation process.
  • Confidentiality Statement: Include a statement on the form about how the information will be used and who will have access to it. It's important to reassure employees that their private information will be protected and used solely for the purpose of assessing and implementing their accommodation request.

Tip #3: Compliance with ADA Guidelines

  • Legal Compliance: The form and the process it initiates should be fully compliant with ADA guidelines. This means understanding what constitutes a 'reasonable accommodation' and the employer's obligations under the law.
  • Flexible and Interactive Process: The form should be a part of an interactive process between the employee, HR, and possibly the employee's supervisor or manager. It's not just about processing a form, but about engaging in a dialogue to find the best solution.
  • Regular Updates and Training: Keep the form and the process it's a part of up-to-date with any changes in ADA regulations. Regular training for HR staff and managers on ADA compliance and handling accommodation requests is also crucial.

Remember: The goal of the ADA Accommodation Request Form is to comply with legal requirements and create an inclusive and supportive work environment for all employees, including those with disabilities.


Reasonable Accommodation Request Form Template

This form complies with the Americans with Disabilities Act (ADA) and the Rehabilitation Act by providing a process for employees or applicants to request reasonable accommodations. The information provided will be kept confidential in accordance with ADA guidelines. For any queries or additional information regarding this form or the accommodation process, please contact the Human Resources Department.

Employee/Applicant Information:

Employee Name: ________________________________

Job Title: ________________________________________

Phone: __________________________________________

Department: ____________________________________

Work Email: _____________________________________

A. Questions to clarify accommodation requested.

What specific accommodation are you requesting? ______________

Detail the reasonable accommodation you are requesting to assist with performing the essential job functions or to participate in the application process.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: _____________If known, please suggest any specific accommodation(s), such as telework, assistive technology, modified work schedule, or other adjustments that would assist you.]

What is the nature of impairment? Briefly describe your impairment under the Americans with Disabilities Act (ADA) or Rehabilitation Act, if applicable.

Is your accommodation request time-sensitive? Yes __ No__

If yes, please explain.

B. Questions to document the reason for the accommodation request.

What, if any, job function are you having difficulty performing?  ______________

What, if any, employment benefit are you having difficulty accessing?  ______________

What limitation interferes with your ability to perform your job or access an employment benefit? Explain how your impairment affects your ability to perform major life activities or specific functions of your job.  ______________

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 in fulfilling the essential functions of your job?

C. Other

Please provide any additional information that might be useful in
processing your accommodation request:  ______________

Signature: ____________________________________________

Could you explain how your impairment affects your ability to perform major life activities or specific functions of your job?Signature Date: ____________________________

Return to ____________________________

Human Resources Use Only

Received by:  ______________

Date Received:  ______________

Accommodation Request Review Process:

The Interactive Process: Detail the steps taken for the interactive process between the employee/applicant and Human Resources to implement the reasonable accommodation.

Determination of reasonable accommodation: Indicate whether the reasonable accommodation request is granted, denied, or if additional information is needed. Include an explanation for the decision and any alternative accommodations offered.

If accommodation not granted, reason for denial (e.g., Undue Hardship): Provide detailed reasoning if the accommodation is deemed to cause undue hardship to the organization.

Implementation Date: __________________

Employee/Applicant Acknowledgment:

Signature: ___________________________________________  

Signature Date: _____________________________________  

Additional Information:

TTY/TDD Users: Please provide TTY/TDD phone number for hearing-impaired employees.  

Contact Information for Equal Employment Opportunity Commission (EEOC):


Fill out this form to download our full guide:

About Disclo

Built by 2x disability-focused founders, the software is a workplace ADA and PWFA accommodations platform for progressive companies focused on making workplaces inclusive for everyone. Disclo is a HIPAA-compliant platform that requests, tracks, and manages workplace accommodations—all in one place.

Disclo makes handling accommodations seamless by combining automation, in-app medical e-verification, out-of-the-box analytics (so you can auto-track against EEOC and ADA standards), and the ability to connect to any HRIS and ATS with pre-built integrations.

Strengthen workplace inclusivity and future-proof ADA and PWFA processes while establishing a digital paper trail for your organization. Learn more at

Curious to see how accommodations can support your employees?

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