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ADA Accommodation Request Form

This document is a request form for employees with disabilities seeking reasonable accommodations to perform their job functions. It includes sections for the employee to describe their requested accommodations and the nature of their condition, as well as a certification section for a health care provider to assess the disability and recommend accommodations. The completed form should be returned to Human Resources along with any supporting documentation.

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0% found this document useful (0 votes)
49 views2 pages

ADA Accommodation Request Form

This document is a request form for employees with disabilities seeking reasonable accommodations to perform their job functions. It includes sections for the employee to describe their requested accommodations and the nature of their condition, as well as a certification section for a health care provider to assess the disability and recommend accommodations. The completed form should be returned to Human Resources along with any supporting documentation.

Uploaded by

lilfella5309
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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REQUEST FOR ACCOMMODATION – DISABILITY

Please complete this form if you have a physical or mental disability and are requesting a
reasonable accommodation to perform the essential functions of your position. Please return this
form to Human Resources.

Date: ________________________
Employee's Name: __________________________________________________
Phone: ________________________ Email: _________________________
Job title: _______________________ Department: ____________________
Manager's Name: __________________________________________________

Please describe the accommodation(s) you are requesting to enable you to perform the essential
functions of your job. If there is more than one accommodation you believe will meet your
needs, please describe all possible accommodations requested:
____________________________________________________________________
____________________________________________________________________

Please describe the nature, extent of the - condition for which you are requesting an
accommodation:
____________________________________________________________________
____________________________________________________________________

Please attach any supporting documentation that may be helpful in evaluating this request for
accommodation, including a completed Certification of Health Care Provider for Reasonable
Accommodation on Page 2 of this form.

Employee Signature: ________________________________________________


Date: _____________________________________________________________
Certification of Health Care Provider for Reasonable Accommodation

Patient’s Name: __________________________________


Date Condition Commenced: _______________________
Probable Duration of Condition: _____________________

This certification will be used for the purpose of assessing whether your patient has a
disability that would benefit from a reasonable accommodation in the workplace. Please
base your assessment on your patient’s present abilities or limitations in performing the
essential functions of the patient’s job as described to you.

1. Does your patient have a disability (i.e., a physical or mental impairment that
substantially limits one or more major life activities)? _____________________
2. If yes, is your patient able to perform the essential functions of the job with an
accommodation?
a. Which function(s) of the job require(s) accommodation? ____________________
________________________________________________________________
b. Your recommendations for accommodations to allow the employee to perform the
essential functions of the job: _________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
c. How long is the accommodation needed? _______________________________
d. Would any other special equipment or arrangements allow the employee to perform
or attend work as required?
3. If yes, is your patient able to perform the essential functions of the job without an
accommodation? _________________________________________________________

Health Care Provider completing this form:


Name: _________________________________________
Address: _______________________________________
Telephone: _____________________________________

___________________________ _______________
Signature of Health Care Provider Date

Common questions

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While the document does not explicitly reference privacy measures, it implicitly ensures privacy by requiring that personal and medical information, such as the nature and extent of the disability, is only submitted directly to Human Resources. It also mentions the inclusion of a confidential Certification of Health Care Provider, which suggests an awareness of the need to protect sensitive health information during the accommodation request process.

The process described in the document could improve the dynamics between an employee and their manager by fostering open communication and understanding regarding the employee's needs and job capabilities. It encourages collaborative problem-solving and mutual respect, where managers become more aware of and responsive to each employee's unique circumstances, leading to a more inclusive workplace. However, it might also strain relationships if disagreements arise over the necessity or feasibility of accommodations.

The document ensures an equitable accommodation process by requiring a detailed and standardized submission of information from both the employee and a healthcare provider. This dual input ensures that accommodation requests are assessed based on verified medical conditions and functional needs rather than assumptions or discrimination. The certification from a healthcare provider provides an objective and professional basis for decision-making, promoting fairness in the accommodation process.

The document addresses the determination of specific accommodations needed by requiring employees to describe the accommodations they believe will enable them to perform essential job functions. Additionally, the Certification of Health Care Provider section asks for detailed assessments from a healthcare provider regarding the patient's ability to perform job functions and recommendations for accommodations, which include specifying necessary equipment or arrangements.

An employee might be asked to list multiple potential accommodations to provide flexibility in addressing their needs and to allow for the evaluation of different solutions. Different accommodations may better suit varying aspects of the employee's disability or the nature of job functions. This approach enables HR and management to consider a range of options that may be viable and effective in supporting the employee's performance in their role.

The healthcare provider's input is crucial in shaping the accommodation process, as they provide an expert evaluation of the employee's medical condition and its impact on major life activities. Their assessment validates the disability status, specifies which job functions may require accommodation, advises on the necessary accommodations, and estimates the duration needed for those accommodations. This medical endorsement helps ensure that accommodations are tailored to genuine, professionally assessed needs.

The primary goal of the Request for Accommodation form is to facilitate employees with physical or mental disabilities in requesting reasonable accommodations that enable them to perform the essential functions of their positions. It seeks to ensure that necessary adjustments or supports are provided to accommodate the employee's condition and functionality in the workplace.

The Request for Accommodation form contributes to enhancing workplace diversity and inclusion by systematically providing employees with the means to seek necessary support and adjustments for their disabilities. By facilitating reasonable accommodations, the document helps to integrate individuals with diverse backgrounds and abilities into the workforce, promoting equal opportunity and ensuring that all employees can participate fully in their roles. This approach fosters a culture of acceptance and inclusivity, enriching organizational diversity.

Potential challenges in implementing healthcare provider recommendations might include budget constraints, lack of necessary resources or technology, and organizational policy limitations. Discrepancies between what is recommended and what is feasible within the workplace might occur, leading to negotiation and possible modifications in the accommodation plan to balance needs with practical realities. Additionally, there could be resistance from other employees or conflict with existing procedures.

The Certification of Health Care Provider section contributes to the decision-making process by providing a professional medical assessment of the employee's condition. It confirms whether the employee has a disability and evaluates the employee's ability to perform job functions with or without accommodation. The healthcare provider's recommendations for specific accommodations and the duration of necessity provide direct input into what adjustments might successfully support the employee's workplace inclusion.

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