ADA Reasonable Accommodation Request Form

Date: ________________________

Employee's Name: __________________________________________________

Phone: ________________________           Email: _________________________

Job title: _______________________           Department: ____________________

Supervisor's name: __________________________________________________

Describe the nature, extent and duration of your disability:

____________________________________________________________________

____________________________________________________________________

Describe the accommodations you believe are needed to enable you to perform the essential functions of this job:

____________________________________________________________________

____________________________________________________________________

Provide the name, address, telephone and fax numbers of your health care provider. The provider may receive a request from us for information regarding your impairment/disability and recommendations for accommodations.

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Attach any supporting documentation that may be helpful in evaluating this request for accommodation.

I authorize the release of information regarding my disability to [Company name} management as deemed necessary by human resources to facilitate this request for accommodation.

Employee signature: ________________________________________________

Date: _____________________________________________________________