California: Disability Accommodation Request Form

[Company Name] is committed to complying with all laws that protect qualified individuals with disabilities. When requested, the company will provide a reasonable accommodation for physical or mental disabilities that interfere with an employee's ability to perform their job or access employment benefits, provided the requested accommodation does not create an undue hardship or pose a direct threat to the health or safety of others in the workplace and/or to the requesting employee. 

[Company Name] is committed to participating in a good faith interactive process with employees to determine whether there is a reasonable accommodation that would allow employees with disabilities to perform their job duties and/or access employment benefits. To request a workplace accommodation, employees should contact [Human Resources/Other Job Title] and complete the form below.

Request for Accommodation Form (To be completed by Employee)

Name:                                                                                                            

Job Title:                                                                                                        

Department:                                                                                                   

Supervisor:                                                                                                    

1. What, if any, job function are you having difficulty performing?
   
   
2. What, if any, employment benefit are you having difficulty accessing?
   
   
3. Please describe the limitation that is interfering with your ability to perform your job or access an employment benefit.
   
   
4. Please list the accommodation(s) you are requesting.
   
   
5. If you are not sure what accommodation you need, please list any suggestions you may have about what options we can explore.
   
   
6. Is your need for accommodation time-sensitive? If so, please explain.
   
   
7. Please provide any additional information that you believe would be useful in processing your request for an accommodation.
   
   

______________________________                               _______________
Employee Signature                                                               Date

Return this form to [Human Resources/Other Job Title]

For employer use:

Received by: ______________________                           Date:__________________

Request    ____approved     _____denied

Additional information:

Express Requests

The HR Knowledge Center has gathered resources on current topics in HR management. Click here to view available topics.