Disability Accommodation Request Form (ADA)

Posted on 03-09-2020

By: Joseph D. Guarino, DLA Piper

This form is a Disability Accommodation Request (ADA) that an employee can use to request a reasonable accommodation. It contains practical guidance and drafting notes.

This form is intended for private employers. It is based on federal law and does not address all potential state law distinctions; thus, you should check any relevant state and local laws.

Employee Information:

Name/Title/Department/Contact Information

 


 


 


 


 

Accommodation Request:

What is the nature of the disability for which you have requested a reasonable accommodation? Please identify any limitations caused by this disability.

 


 


 


 


 

Please list the job functions you are having trouble performing or will have trouble performing due to a disability.

 


 


 


 


 


 

Please describe the type of reasonable accommodation you require that would allow you to perform the essential functions of your job. If possible, please identify a specific accommodation. If you are aware of a specific piece of equipment that you require, please identify it.

 


 


 


 


 


 

For what time period will the reasonable accommodation be needed? Do you anticipate that your need for the accommodation will be recurring? Please state whether this request is time sensitive.

 


 


 


 


 


 


 


 






[employee signature] [date]




[request received by] [date]


All medical information obtained by the Company with respect to an employee’s request for an accommodation will be kept confidential by the Company and placed in separate files.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits covered employers from requesting or requiring genetic information of an individual or an individual’s family member, except as specifically allowed by this law. To comply with GINA, the Company asks that employees not provide any genetic information when responding to this request for medical information. Genetic information, as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

If you have any questions about this form, the information to be provided or the status of any accommodation request, please contact [identify appropriate Company official by title].

Drafting notes and alternate clauses related to this Disability Accommodation Request (ADA) form are available in Lexis Practice Advisor.


Form provided by Joseph D. Guarino, a partner at DLA Piper. His practice emphasizes the representation of management and employers in labor and employment matters, including both preventive counseling and litigation. His clients have a national and worldwide presence and primarily conduct business in the healthcare, dietary supplement, transportation, retail, and financial services industries.


To find this article in Lexis Practice Advisor, follow this research path:

RESEARCH PATH: Labor & Employment > Attendance, Leaves, and Disabilities > The ADA and Disability Management > Forms

Related Content

For a detailed discussion of the Americans with Disabilities Act (ADA) and disability management, see

> AMERICANS WITH DISABILITIES ACT: GUIDANCE FOR EMPLOYERS

RESEARCH PATH: Labor & Employment > Attendance, Leaves, and Disabilities > The ADA and Disability Management > Practice Notes

For best practices for drafting disability and reasonable accommodation policies, see

> DISABILITY AND REASONABLE ACCOMMODATION POLICIES: KEY DRAFTING TIPS

RESEARCH PATH: Labor & Employment > Attendance, Leaves, and Disabilities > The ADA and Disability Management > Practice Notes

For a form to document the determination of an employee’s request for a reasonable accommodation under the ADA, see

> DISABILITY ACCOMMODATION REQUEST RESOLUTION (ADA)

RESEARCH PATH: Labor & Employment > Attendance, Leaves, and Disabilities > The ADA and Disability Management > Forms

For state-specific disability accommodation policies, see the Attendance Policy and Disability Accommodation column of

> ATTENDANCE, LEAVES, AND DISABILITIES STATE EXPERT FORMS CHART

RESEARCH PATH: Labor & Employment > Attendance, Leaves, and Disabilities > The ADA and Disability Management > Forms

For information on state laws concerning disability accommodation, see the relevant state law practice notes in

> DISCRIMINATION, HARASSMENT, AND RETALIATION STATE PRACTICE NOTES CHART

RESEARCH PATH: Labor & Employment > State Law Surveys and Content Guides > State Law Content Guides > Forms