Workplace Accessibility Accommodation Request Form

Workplace Accessibility Accommodation Request Form — Form Fields

This operations template includes 12 fields. Allow employees to formally request workplace accessibility accommodations under ADA or equivalent legislation. Free to customize and use on ZenBuild.

• Employee Full Name (text, required)
• Employee Email (email, required)
• Department (text, required)
• Manager Name (text, required)
• Accommodation Type (dropdown selection, required) — options: Physical workspace modification, Remote/hybrid work arrangement, Modified schedule/hours, Assistive technology, Communication support, Transportation assistance, Other
• Description of accommodation needed (long text, required)
• How does this accommodation support your ability to perform your job? (long text, required)
• Is this related to a temporary or permanent condition? (dropdown selection, required) — options: Temporary (expected recovery), Permanent/long-term, Episodic/variable, Prefer not to disclose
• Have you provided medical documentation? (dropdown selection, required) — options: Yes - attached, Yes - will provide separately, Documentation not yet available, Request does not require documentation
• Urgency (dropdown selection, required) — options: Immediate, Within 2 weeks, Within 1 month, At next review cycle
• HR/ADA Coordinator Assigned (dropdown selection, required) — options: Yes, Pending assignment
• Additional context or special considerations (long text, optional)