10 Mar 2020

Disability Accommodation Request Resolution Form (ADA)

By: Sara Kula, DelBello Donnellan Weingarten Wise & Wiederkehr, LLP

An employer may use this form to document the determination of an employee’s request for a reasonable accommodation under the Americans with Disabilities Act (ADA). The 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.

The ADA requires an employer to provide reasonable accommodations to qualified individuals with disabilities who are employees or applicants for employment, unless to do so would cause an undue hardship on the operation of the employer’s business. 42 U.S.C. § 12112(b)(5). This form is meant to be completed and provided to the employee after the employer has engaged in an interactive process with the employee concerning the employee’s accommodation request. While providing a written resolution form to an ADA accommodation request is not required, it is recommended as a best practice.

Employee (identified below) has requested an accommodation related to a disability. [Company name] (the Company) has engaged in good faith written and/or oral communications with the employee regarding the employee’s accommodation needs, potential accommodations, and, where appropriate, difficulties that the proposed accommodations could pose for the Company. This document provides a record of the Company’s determination concerning the employee’s accommodation request. It does not, and is not intended to, document the Company’s complete analysis resulting in its determination.
I. Information Regarding Request Employee Name: Employee Job Title: Supervisor: Date of Accommodation Request: Nature of Accommodation Requested (check all applicable):
◻ Job restructuring ◻ Leave ◻ Modified or part-time schedule ◻ Modified workplace policy ◻ Reassignment to vacant position ◻ Modification to equipment or facilities ◻ Other
Description of Accommodation Requested
II. Documentation Relating to Request Were Medical Records Requested to Support Accommodation Request (check one)?
◻ YES	◻ NO
Were Medical Records Provided to Support Accommodation Request (check one)?
◻ YES	◻ NO	◻ YES, BUT ADDITIONAL INFORMATION/CLARIFICATION IS REQUIRED
III. Determination Employer’s Decision (check one and complete corresponding information below):
◻ Accommodation request granted ◻ Alternative effective accommodation offered, and (check one): ◻ Accepted by employee ◻ Rejected by employee ◻ Accommodation denied
If an accommodation was granted or an alternative effective accommodation was offered, complete the following information: Description of Accommodation: Accommodation Start Date: Accommodation End Date (if applicable): Accommodation Review Date (if applicable): If an accommodation was denied, complete the following information: Reason for Denial (check primary reason):
◻ Employee did not respond to information requested and/or additional information is necessary to evaluate the accommodation request ◻ The employee’s medical condition does not meet the ADA’s definition of disability ◻ The accommodation would not be effective ◻ The accommodation would require removal of an essential job function ◻ The medical documentation provided does not adequately support the request ◻ The accommodation would require lowering of a performance or production standard ◻ The accommodation would cause an undue hardship to the organization ◻ The accommodation would create a direct threat to the safety of employee or others ◻ Other
Further Explanation of Denial: Completed by:
[employee signature]		[date]
Statement to Employee If any of the information in this document is incorrect, please inform [company representative name] as soon as possible. If you wish to request reconsideration of this determination, you must submit a written request to [company representative name], [title] at [contact information of company representative] within [number] of days of receiving a denial.
[employee signature acknowledging receipt]		[date]
Drafting notes and alternate clauses related to this Disability Accommodation Request Resolution (ADA) form are available in Lexis Practice Advisor.

Form provided by Sara Kula, a partner at DelBello Donnellan Weingarten Wise & Wiederkehr, LLP, where she works with her clients to create and implement HR compliant policies and practices, provides guidance on difficult employee issues, and advocates for clients when disputes arise. Sara specializes in the areas of wage and hour, leave management and disability accommodations, discrimination and harassment, retaliation, employment agreements, performance management, workplace investigations, and other human resources best practices.

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Disability Accommodation Request Resolution Form (ADA)

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