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Accommodation and Compliance Series:
Sample Reasonable Accommodation Form for Employers


JAN’s Accommodation and Compliance Series is designed to help employers determine effective accommodations and comply with Title I of the Americans with Disabilities Act (ADA). Each publication in the series addresses a specific medical condition and provides information about the condition, ADA information, accommodation ideas, and resources for additional information.

The Accommodation and Compliance Series is a starting point in the accommodation process and may not address every situation. Accommodations should be made on a case by case basis, considering each employee’s individual limitations and accommodation needs. Employers are encouraged to contact JAN to discuss specific situations in more detail.

For information on assistive technology and other accommodation ideas, visit JAN's Searchable Online Accommodation Resource (SOAR) at http://askjan.org/soar.

Sample Reasonable Accommodation Request Form for Employers

The Americans with Disabilities Act of 1990 (ADA) requires employers to provide reasonable accommodations for qualified employees with disabilities, unless such accommodations pose an undue hardship (e.g., too costly, too extensive, too substantial, too disruptive). In general, the employee with a disability is responsible for letting the employer know that an accommodation is needed to perform essential job functions or to receive equal benefits and privileges of employment. Employers are not required to provide accommodations if they are not aware of the need.

According to the Equal Employment Opportunity Commission (EEOC), the federal agency charged with enforcing the ADA, an accommodation request does not have to be in writing and the ADA does not include specific guidelines or forms for requesting reasonable accommodation. However, some employers find it useful to document accommodation requests and want to have a standard form for employees to use when requesting accommodations. For these employers, JAN developed a sample accommodation request form. Please note that this sample is to be used as a guide only and is not legal advice. If legal advice is needed, contact a legal service.

Download (.doc) Sample Reasonable Accommodation Request Form for Employers

You can contact JAN to discuss a specific accommodation situation.

Updated 09/05/08


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