Americans with Disabilities Act (ADA) Accommodation Request Form Date: EMPLOYEE INFORMATION (PART 1) 2026

1. Click ‘Get Form’ to open the ADA Accommodation Request Form in the editor.
2. Begin by filling out your personal information in the EMPLOYEE INFORMATION section. Enter your name, work site, address, position, city, state, zip code, home phone, cell phone, and email.
3. In the detailed response section, clearly describe the situation or condition prompting your accommodation request. Be specific about the nature of your impairment and whether it is chronic or temporary.
4. Next, outline how your job responsibilities will be affected by this accommodation request. This helps clarify your needs to HR.
5. Specify the accommodations you are proposing and provide an anticipated length for these accommodations.
6. Finally, sign and date the form at the bottom to validate your request before submitting it to HR.

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