Disability Accommodation Request Form (ADA)

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.

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

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