ADA Accommodation Request

we don't require use of a form for ADA accommodation, but I am looking for a basic request form for an employee and also a form to be sent to the physician along with a job description (ie, when asking whether this person can perform essential functions without accommodation, and if not what accommodations are needed. Anyone out there have ideal form(s) they can share?


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  • I had developed a form for our agency years ago, but I think it is far more than you indicate by "basic" and because there are so many possibilities, there may not be a "basic" form template out there. Your best bet is to develop your own with the information you need or want.

    I suggest the information you request include some or all of the following areas:

    1. Diagnosis of medical condition

    2. Major life activities impacted (give a short list as examples) or how
    does the condition limit the individual

    3. Length of time the condition has existed -- will it exist

    4. If the individual takes any mitigating or remedial measures, such as
    medication, for the condition -- if so, the impact of the measure

    5. The condition's impact, if any, on the employee's ability to perform the
    essential duties of the job or to meet the various requirements of the
    job (include a list of the essential and non-essential job duties and the
    physical, mental, and enviormental requirements/demands of the job).

    6. What accommodations the doctor suggests that would allow the employee to
    perform the essential duties of the job (this question will be evaluated if
    the employee is qualified for reasonable accommodation as a disabled
    individual and needs accommodation to perform the essential duties of the

    Of course you want to include a release of information, have a space for the doctor to sign and date the form as well as indicate license status, office information, etc. Your letter should state that why you are requesting the information and that the information will be shared with the employee, but otherwise will be kept confidential, and that you may need to contact the doctor for follow up information. It's probably a good idea to call the doctor's office first to let them know you are sending over an "ADA inquiry."

    Put a deadline you'd like to have the form returned by (include a SASE envelop).

    You can have the employee take it but at least make sure if you are sending it directly to the doctor that you send a copy to the employee (of course all of this should have been discussed with the employee early on in the process).

    Be aware of any particular your state law provisions that alter ADA inquiries.
  • I was looking for info regarding the exact same thing. I recommend that you check out the Job Accommodation Network website at [url][/url] (the DOL disabilities includes it as a link). JAN has some sample forms used by the City of Sacramento for accommodation request, medical information, and medical release. Look under: points of interest/ disability resources/ ADA Policy, Form, and Checklist Samples/ Sample ADA Policies/ City of Sacramento.

    On a side note, the JAN website is VERY useful if a bit confusing to navigate. I even has lists of accommodations by disability.
  • thanks for the tip, and to others who replied! I'll take a look.
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