Disability Accommodation Request for Workplace

Disability Accommodation Request for Workplace — Form Fields

This applications template includes 10 fields. Form for employees to request workplace accommodations related to a disability or medical condition. Free to customize and use on ZenBuild.

• Employee Full Name (text, required)
• Work Email Address (email, required)
• Department and Job Title (text, required)
• Manager's Name (text, required)
• Type of Accommodation Requested (dropdown selection, required) — options: Physical Workspace Modification, Flexible Schedule, Remote Work, Assistive Technology, Modified Duties, Other
• Describe the accommodation needed and why (long text, required)
• How will this accommodation enable you to perform your job? (long text, required)
• Supporting Medical Documentation (optional) (file upload, optional)
• Urgency of Request (dropdown selection, required) — options: Immediate, Within 2 weeks, Within 1 month, No Specific Timeline
• Best time to contact you for follow-up (text, optional)