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ADA Reasonable Accommodation Request

ADA Reasonable Accommodation Request

Submitted pursuant to the Americans with Disabilities Act of 1990 (42 U.S.C. §12101 et seq.) and the ADA Amendments Act of 2008

Date: [Request Date]

TO: [HR Contact Name], [HR Title]

[Company Name]

[Company Address]

FROM: [Employee Name], [Job Title], [Department] Department

Employee ID: [Employee ID]

Phone: [Employee Phone] | Email: [Employee Email]

1. PURPOSE OF THIS REQUEST

I, [Employee Name], currently employed as [Job Title] in the [Department] Department at [Company Name], am submitting this formal request for a reasonable accommodation pursuant to Title I of the Americans with Disabilities Act of 1990 (42 U.S.C. §12101 et seq.), as amended by the ADA Amendments Act of 2008 (ADAAA), and applicable EEOC regulations at 29 CFR Part 1630. I understand that [Company Name] is required by law to engage in an interactive process to determine whether a reasonable accommodation can be provided that would enable me to perform the essential functions of my position.

2. DESCRIPTION OF DISABILITY AND FUNCTIONAL LIMITATIONS

I have a disability as defined under 42 U.S.C. §12102, which constitutes a physical or mental impairment that substantially limits one or more major life activities. Specifically:

Nature of Disability or Medical Condition: [Disability Description]

Major Life Activity Substantially Limited: [Major Life Activity]

Impact on Job Functions: [Job Function Limitation]

I understand that I am not required to disclose a specific medical diagnosis in this request. Any medical information I provide will be maintained in a confidential file separate from my general personnel record, as required by 29 CFR §1630.14(d).

3. REQUESTED ACCOMMODATION(S)

I am requesting the following reasonable accommodation(s) to enable me to perform the essential functions of my position:

[Accommodation Requested]

How the Accommodation Will Enable Performance of Essential Job Functions:

[Accommodation Effectiveness]

I understand that the accommodation requested must be reasonable and must not impose an undue hardship on [Company Name] as defined in 42 U.S.C. §12111(10). I am willing to discuss alternative accommodations that achieve the same result if the specific accommodation(s) requested above are not feasible.

4. PRIOR ACCOMMODATION HISTORY

I have previously requested accommodations from [Company Name]. The details of that prior request and its outcome are as follows:

[Prior Accommodation Details]

5. MEDICAL DOCUMENTATION

Medical Documentation Enclosed: [Medical Doc Provided]

Supporting Healthcare Provider: [Medical Provider]

Healthcare Provider Contact: [Medical Provider Contact]

Pursuant to EEOC guidance on disability-related inquiries, I am providing (or am prepared to provide upon request) documentation from my healthcare provider sufficient to verify the existence of my disability and its functional limitations. I request that any such documentation be maintained in strict confidence and used solely for the purpose of evaluating this accommodation request.

6. REQUESTED START DATE AND ADDITIONAL INFORMATION

I respectfully request that the accommodation be in place no later than [Preferred Start Date]. I understand that implementation may require a reasonable period to arrange and am willing to discuss interim measures during that time.

Additional Information: [Additional Information]

7. INTERACTIVE PROCESS

I acknowledge that the ADA requires both the employer and employee to engage in an interactive process in good faith to identify an effective, reasonable accommodation (29 CFR §1630.2(o)(3); EEOC Enforcement Guidance on Reasonable Accommodation, 2002). I am fully prepared to participate in this process and to provide any additional information, including medical documentation, necessary to evaluate this request.

Please contact me at [Employee Phone] or [Employee Email] to schedule a meeting or to request further information. I request a written response to this accommodation request within a reasonable timeframe.

8. CERTIFICATION

I certify that the information provided in this request is true, accurate, and complete to the best of my knowledge. I am making this request in good faith pursuant to my rights under the Americans with Disabilities Act of 1990, as amended, and applicable EEOC regulations.

Employee Signature: ______________________________

Printed Name: [Employee Name]

Date: [Signature Date]

FOR HR USE ONLY:

Date Received: _______________

Received By: _______________

Tracking Number: _______________

Employee

________________

Signature

Date: ________________

Maintained by Vladislav Sergienko, Founder·Template last modified: ·Report an error

What Is a ADA Reasonable Accommodation Request?

An ADA Reasonable Accommodation Request in the United States puts a formal request before the recipient and sets out the grounds supporting it.

Under the ADA, a covered employer — one with 15 or more employees — is prohibited from discriminating against a qualified individual with a disability and is required to provide reasonable accommodations unless doing so would impose an undue hardship on the business. A reasonable accommodation is any modification or adjustment to a job, work environment, or the way things are usually done that enables a qualified person with a disability to enjoy equal employment opportunities. Examples include modified work schedules, ergonomic equipment, remote work arrangements, reassignment of marginal job functions, leave under the FMLA, accessible parking, and modified training materials.

The accommodation request is not merely a courtesy — it is the legal trigger that obligates the employer to act. Courts have consistently held that employers are not required to provide accommodations they do not know are needed. By submitting a formal written request, the employee creates a dated record that starts the clock on the employer's interactive process obligation under 29 CFR §1630.2(o)(3). EEOC enforcement guidance emphasizes that the interactive process must begin promptly and proceed in good faith by both parties.

The ADAAA of 2008 was enacted in direct response to two Supreme Court decisions — Toyota Motor Manufacturing v. Williams (2002) and Sutton v. United Air Lines (1999) — that had interpreted the definition of disability so narrowly that few conditions qualified. The ADAAA rejected those interpretations and reinstated the ADA's original broad protective intent. As a result, conditions including diabetes, cancer in remission, epilepsy, major depression, PTSD, HIV infection, and many chronic conditions now routinely qualify under the ADA even when controlled by medication or treatment.

When Do You Need a ADA Reasonable Accommodation Request?

You should submit a formal ADA Reasonable Accommodation Request whenever a physical or mental condition substantially limits your ability to perform one or more of your essential job functions, and you need some modification to the workplace, schedule, equipment, or policy to address that limitation. The request is necessary — and often urgent — in several common situations.

New disability or worsening condition: If you are newly diagnosed with a disability or your existing condition has worsened to the point that it now significantly affects your work performance, you should submit a request as soon as practicable. Courts have held that unreasonable delay in requesting accommodations can complicate your legal position.

Return from medical leave: If you are returning from FMLA or other medical leave with ongoing limitations, an accommodation request ensures the employer knows what adjustments you need to continue working effectively. Without a formal request, the employer may not know you need assistance.

Performance issues caused by disability: If your disability is causing performance problems — such as absenteeism due to a chronic condition, difficulty concentrating due to a mental health condition, or physical limitations affecting productivity — an accommodation request stops the performance management clock. An employer cannot lawfully terminate an employee for disability-related performance issues if the employer failed to engage in the accommodation process.

Pre-emptive accommodation for a new role: If you are accepting a job offer or being transferred to a new position with different physical or cognitive demands, you may need to request accommodations before your start date.

The request should always be in writing. Verbal requests can be forgotten, disputed, or never formally processed. A written, signed, and dated document creates an unambiguous record of when the request was made, what was requested, and who received it — all critical facts in any future EEOC charge or litigation under the ADA.

What to Include in Your ADA Reasonable Accommodation Request

A well-drafted ADA Reasonable Accommodation Request should contain several essential components that establish the legal foundation for your request and help the interactive process.

Employee and employer identification: The document should clearly identify you by full name, job title, department, and employee ID, and should be addressed to the specific HR manager, HR director, or supervisor with authority to act on accommodation requests. Addressing the letter to a specific, named individual reduces the risk of it being lost or ignored.

Description of the disability and functional limitations: You do not need to disclose your specific diagnosis, but you must describe the nature of your impairment and how it substantially limits one or more major life activities as defined in 42 U.S.C. §12102. Be specific about how the condition affects your ability to perform the essential functions of your particular job — this is the key legal connection the EEOC looks for.

Specific accommodation request: Clearly describe the accommodation(s) you are seeking. Vague requests like 'I need help' are difficult for employers to act on. Instead, specify the adjustment needed: a standing desk, modified schedule, permission to work from home on certain days, a reassignment of a particular duty, or a leave of absence. If you are uncertain what accommodation would work best, you may request that the employer engage in the interactive process to identify options together.

Explanation of effectiveness: Connect the requested accommodation to your ability to perform your essential job functions. This demonstrates that the accommodation is directed at enabling you to do your job — not simply to receive a benefit — which is the legal standard under the ADA.

Medical documentation reference: While you do not attach your full medical records, indicate whether you are providing supporting documentation from your healthcare provider, and identify the provider. EEOC guidance states that employers may request documentation sufficient to establish the disability and functional limitations, but may not demand your entire medical history.

The forms-legal.com ADA Reasonable Accommodation Request template includes all six sections — employee identification, disability description, functional limitations, specific accommodation requested, medical documentation reference, and dated signature — aligned with EEOC guidance and 29 CFR Part 1630 requirements.

Date and signature: A dated, signed request is significantly stronger than an undated or unsigned one. The date establishes when the employer's interactive process obligation was triggered under 29 CFR §1630.2(o)(3). Keep a copy of every accommodation request you submit.

Sources & Citations

Statutory citations link to official government sources.

  1. 42 U.S.C. §12102US – Cornell LII
  2. 29 CFR §1630.2US – eCFR
  3. ADAUS – Cornell LII
  4. FMLAUS – Cornell LII

Cite this page

Reference this free template in an article, syllabus, or research note:

APA

Forms Legal. (2026). ADA Reasonable Accommodation Request (United States) [Legal document template]. Forms Legal. https://forms-legal.com/usa/employment/forms/ada-accommodation-request

MLA

"ADA Reasonable Accommodation Request (United States)." Forms Legal, 2026, https://forms-legal.com/usa/employment/forms/ada-accommodation-request.

BibTeX
@misc{formslegal-ada-accommodation-request,
  author       = {{Forms Legal}},
  title        = {ADA Reasonable Accommodation Request (United States)},
  year         = {2026},
  howpublished = {\url{https://forms-legal.com/usa/employment/forms/ada-accommodation-request}},
  note         = {Free legal document template. Based on Americans with Disabilities Act (42 U.S.C. §12101)}
}

Frequently Asked Questions

Based on Americans with Disabilities Act (42 U.S.C. §12101) — Template last modified June 2026Verify the source →

This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer

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