This section captures essential employee identification and precise workplace location data to ensure accurate delivery and installation of accommodations. All fields marked mandatory must be completed to process the request.
Employee ID Number
Full Legal Name
Official Job Title
Department/Division
Direct Supervisor Name
Supervisor Email Address
Employee Corporate Email
Employee Direct Phone/Extension
Employment Start Date
Anticipated Return-to-Office Date
Current Employment Status
Full-Time Permanent
Part-Time Permanent
Fixed-Term Contract
Probationary Period
Other
Primary Office Building Identifier
Floor Number
Floor Zone/Section Code
Exact Workstation Identifier
Floorplan Grid Coordinate (X-Axis)
Floorplan Grid Coordinate (Y-Axis)
Is this workstation location adjacent to accessible pathways (ramps, wide corridors)?
Has this employee worked remotely for more than 6 consecutive months?
Date remote work commenced
Current workstation configuration (select all that apply)
Standard fixed-height desk
Adjustable-height desk
Dual monitor setup
Single monitor setup
Laptop-only setup
Task chair with arms
Task chair without arms
Standing mat
Footrest
Document holder
Wrist rests
Keyboard tray
Other specialized equipment
Describe current pain points or challenges with existing workstation setup
This section documents medical justification for requested accommodations. All information must be supported by current medical certification from a licensed healthcare provider. Upload supporting documentation where indicated.
Do you have current medical documentation (within the last 12 months) supporting this accommodation request?
Upload medical certification or healthcare provider letter (PDF, JPG, PNG accepted)
Please obtain current medical documentation from a licensed healthcare provider before submitting this request. Processing cannot proceed without valid certification.
Primary Diagnosis Category
Healthcare Provider Name & Credentials
Date of Last Medical Evaluation
Date of Next Scheduled Follow-up Evaluation
Primary functional limitations affecting work performance (select all that apply)
Limited sitting tolerance
Limited standing tolerance
Reduced upper extremity dexterity
Reduced grip strength
Limited neck/head rotation
Visual acuity limitations
Hearing limitations
Cognitive processing limitations
Balance/coordination challenges
Respiratory limitations
Other
Maximum continuous sitting tolerance (minutes)
Maximum continuous standing tolerance (minutes)
Do you require periodic position changes (sit/stand) throughout the workday?
Do you have weight-bearing restrictions?
Maximum weight limit (kg/lbs)
Do you require assistive technology for computer access?
Types of assistive technology required
Screen reader software
Speech recognition software
Alternative input device
Screen magnification
Braille display
Other
Have you previously received workplace accommodations at this or another employer?
Describe previous accommodations and their effectiveness
Additional medical considerations or precautions for installation/setup team
Detail each piece of specialized equipment requested. Provide complete specifications to ensure procurement of correct models. Cost estimates should include all associated fees. Use the table below for multiple items.
Equipment Request & Cost Estimation Matrix
Equipment Category | Specific Product Name/Model | Manufacturer | Part Number/SKU | Quantity Required | Unit Price (Local Currency) | Shipping & Handling | Installation/Setup Fee | Line Item Total | Clinical/Functional Justification | ||
|---|---|---|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | H | I | J | ||
1 | Ergonomic Task Chair | Freedom Headrest Chair | Humanscale | FRH-001 | 1 | $1,200.00 | $150.00 | $75.00 | $1,425.00 | Reduces lumbar pressure for L4-L5 disc herniation | |
2 | Height-Adjustable Desk | Electric Standing Desk 72" | Uplift Desk | V2-72 | 1 | $800.00 | $100.00 | $50.00 | $950.00 | Enables 50/50 sit-stand rotation per medical requirement | |
3 | Alternative Keyboard | Kinesis Advantage2 | Kinesis | KB600 | 1 | $350.00 | $25.00 | $0.00 | $375.00 | Reduces ulnar deviation for chronic tendonitis | |
4 | $0.00 | ||||||||||
5 | $0.00 | ||||||||||
6 | $0.00 | ||||||||||
7 | $0.00 | ||||||||||
8 | $0.00 | ||||||||||
9 | $0.00 | ||||||||||
10 | $0.00 |
Primary funding source for this accommodation
Department operational budget
Central accessibility fund
Insurance/workers compensation
Government subsidy program
Other
Is this request time-sensitive due to medical urgency?
Required completion date
Have you researched or trialed this specific equipment before?
Describe trial experience and why this model was selected
Are alternative or refurbished equipment options acceptable if they meet functional requirements?
Special ordering instructions or vendor preferences
Upload product specification sheet or brochure (optional)
This section ensures the requested modifications can be safely and effectively implemented within the existing facility infrastructure. Facilities Operations must verify all spatial, electrical, and safety requirements before approval.
Has a Facilities Operations representative physically inspected the workstation location?
Date of site inspection
Site inspection must be scheduled within 5 business days. Request cannot proceed to final approval without completed inspection.
Infrastructure Verification Checklist
Infrastructure Component | Verified Present | Specification Details | Requires Modification | Estimated Modification Cost | Modification Notes | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | Dedicated electrical outlet within 1.5m | Yes | 120V/20A circuit | $0.00 | Existing outlet meets requirements | ||
2 | Network data port within 1.5m | Yes | Cat6a Ethernet | $0.00 | Direct connection available | ||
3 | Adequate knee clearance (minimum 68cm) | Current clearance: 55cm | Yes | $250.00 | Requires desk modification or replacement | ||
4 | Emergency egress path width (minimum 91cm) | Yes | Path width: 110cm | $0.00 | No obstruction | ||
5 | Overhead lighting adjustable | Fixed fluorescent | Yes | $180.00 | Install dimmable LED panel | ||
6 | |||||||
7 | |||||||
8 | |||||||
9 | |||||||
10 |
Will installation require after-hours or weekend access to minimize disruption?
Specify preferred installation windows
Does the equipment require special environmental conditions (temperature, humidity, dust-free)?
Describe required environmental parameters
Will the installation impact adjacent workstations or shared spaces?
Describe impact and mitigation plan
Installation complexity assessment
Simple - Employee self-setup with remote guidance
Moderate - Facilities team installation within 2 hours
Complex - Requires specialized contractor and multiple days
Critical - Requires structural modifications and permits
Are there any building code or fire safety considerations for this modification?
Describe code considerations and required approvals
Upload current workstation photos (minimum 4 angles: front, side, rear, floor)
Upload floorplan markup showing proposed modifications (PDF or CAD format)
Final authorization requires dual approval from HR Business Partner and Facilities Operations Manager. Both parties must review all preceding sections and confirm implementation feasibility and policy compliance.
HR Business Partner Review: Does this request comply with company accommodation policies and procedures?
Describe policy deviations and required exception approvals
HR Business Partner Name
HR Business Partner Employee ID
HR Business Partner Review Timestamp
Facilities Operations Manager Review: Are all infrastructure, safety, and space requirements satisfactorily addressed?
List outstanding issues preventing approval
Facilities Operations Manager Name
Facilities Operations Manager Employee ID
Facilities Operations Manager Review Timestamp
Confirmed Installation/Implementation Date
Post-Implementation Follow-up Review Date (recommended 30 days after installation)
Has the employee been notified of the approved accommodations and timeline?
Communication plan details
Does the employee require training on new equipment operation?
Training plan and scheduled date
HR Business Partner Digital Signature
Facilities Operations Manager Digital Signature
Additional comments or special instructions for implementation team
To configure an element, select it on the form.