Americans with Disabilities Act (ADA) Employee Request for Accommodation

This form must be completed when an employee is making a request for accommodation due to a documented disability. To be eligible for a reasonable accommodation under the Americans with Disabilities Act (ADA), you must be able to perform the essential functions of your position with or without an accommodation, and have a qualifying disability that limits a major life function.

Employee Name:	Employee Phone:
Supervisor:	Supervisor Phone:
Department:	Date:
Please describe which major life activity your medical condition limits. (For example: caring for oneself, performing manual tasks, walking, seeing, hearing, sitting, speaking, breathing, learning, remembering, concentrating, etc.)
2. Describe how your medical condition limit your ability to perform the essential functions of your job. Using your Employee Work Profile and Addendum A (if applicable), identify the essential functions affected and be specific about how the medical condition impairs your ability in each instance.
3. Specifically describe the accommodation(s) you are proposing.
4. Please add any comments you feel may be helpful in our consideration of your request:
Employee Signature:	Date:

Revised April 2018