Employee Reasonable Accommodation Request Form

Let employees request workplace adjustments for health reasons: the type of accommodation, related diagnoses, impact on their duties, and supporting medical documentation. It helps the company handle each case respectfully and with a complete paper trail.

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In the Claude connectors directory

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Information

Full Name

First Name

Last Name

Today's Date

Address

Street Address

City

State / Province

ZIP / Postal Code

Email

Phone Number

Preferred Method of Contact

Department / Unit

Information

Type of Accommodation

Please identify the specific diagnosis(es) related to your request for accommodations.

Date(s) of Diagnosis (es)

1. Explain how your impairment affects your ability to perform the essential functions of your job

2. List the accommodation(s) you are requesting. Please be as specific as you can.

3. Add any comments you feel may be helpful in our consideration of your request.

4. Unless the disability and need for a reasonable accommodation is obvious that no medical document is needed, please include medical verification of the impairment(s

Medical Documentation

Max 10 MB per file

Information

Signature

First Name

Last Name

Date Submitted

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