Please provide accurate information to ensure efficient processing of your accommodation request. All fields marked as mandatory must be completed.
Employee ID
Full Legal Name
Department
Engineering & Technology
Sales & Marketing
Finance & Accounting
Human Resources
Operations & Logistics
Customer Service
Legal & Compliance
Research & Development
Facilities & Administration
Other
Job Title/Role
Work Email Address
Phone Extension/Direct Line
Direct Manager/Supervisor Name
Employment Type
Full-Time Permanent
Part-Time Permanent
Full-Time Temporary
Part-Time Temporary
Contractor
Intern
Original Hire Date
Primary Work Arrangement
On-Site (100% office-based)
Hybrid (split between office and remote)
Remote (100% home-based)
Mobile/Field-based
Please specify your typical weekly office schedule (e.g., Monday, Wednesday, Friday)
Please describe your home office setup and why accommodation is still necessary
Primary Workstation Building/Campus Name
Floor/Level
Zone/Wing/Area
Desk/Workstation Number
Describe Your Current Workstation Setup
How long have you been experiencing the current issue?
Less than 1 month
1-3 months
3-6 months
6-12 months
More than 1 year
Since beginning of employment
Rate the urgency of this request
This section documents the medical necessity for accommodations. All information provided will be kept confidential and shared only with those involved in the accommodation process. A valid physician's certification is typically required for ergonomic and assistive technology requests.
Have you been formally diagnosed with a medical condition that affects your ability to perform job functions?
Please describe the diagnosed condition(s) and how they impact your work
Do you have current physician certification (within the last 12 months) recommending workplace accommodations?
Upload Physician Certification/Medical Documentation
Please obtain physician certification before proceeding. Contact HR for a standard Medical Assessment Form to share with your healthcare provider.
Date of Physician Certification
Nature of Medical Condition
Musculoskeletal Disorder
Neurological Condition
Visual Impairment
Hearing Impairment
Respiratory Condition
Cardiovascular Condition
Mental Health Condition
Chronic Pain Condition
Cognitive/Developmental Condition
Other
Is this condition temporary or permanent?
Temporary (expected to improve)
Permanent (long-term or lifelong)
Unknown/Under evaluation
Expected recovery date
Select all physical limitations that apply to your condition
Limited range of motion in upper body
Limited range of motion in lower body
Reduced grip strength or hand dexterity
Inability to sit for extended periods
Inability to stand for extended periods
Chronic pain when using standard equipment
Visual limitations requiring screen magnification
Hearing limitations requiring visual alerts
Fatigue or stamina issues
Cognitive processing limitations
Other
Describe specific upper body limitations
Describe specific lower body limitations
Describe cognitive processing limitations and required support
Describe other limitations
Rate the severity of functional limitations in these key areas
No limitation | Mild limitation | Moderate limitation | Severe limitation | Unable to perform | |
|---|---|---|---|---|---|
Lifting or carrying objects | |||||
Repetitive hand/arm movements | |||||
Sustained sitting posture | |||||
Sustained standing posture | |||||
Viewing standard computer screens | |||||
Using standard keyboard/mouse | |||||
Concentrating for extended periods | |||||
Adapting to changes in routine |
Maximum weight you can safely lift (in kg)
Maximum continuous sitting time without break (in minutes)
Maximum continuous standing time without break (in minutes)
Have you received workplace accommodations previously for this or any other condition?
Describe previous accommodations and their effectiveness
Additional medical information or context HR should consider
Provide detailed specifications for all requested equipment. Include cost estimates and vendor information. The HR team will verify pricing and manage procurement upon approval.
Accommodation Request Category
Ergonomic Furniture (chairs, desks, footrests)
Assistive Technology (software, screen readers)
Input Devices (specialized keyboards, mice, trackballs)
Visual Aids (monitor arms, screen magnifiers, lighting)
Hearing Assistance (amplified headsets, visual alert systems)
Mobility Support (wheelchair accessible desks)
Environmental Controls (air purifiers, temperature control)
Cognitive Support Tools (organizational software, timers)
Other Specialized Equipment
Detailed Equipment Request & Cost Breakdown
Item Name & Model | Vendor/Manufacturer | Quantity Required | Unit Cost (USD) | Total Cost | Justification & Specific Need | Product URL/Catalog Number | ||
|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | ||
1 | Adjustable Height Electric Desk - FlexiSpot E7 | FlexiSpot | 1 | $499.99 | $499.99 | Required for alternating between sitting and standing due to chronic lower back pain | https://flexispot.com/e7-desk | |
2 | Ergonomic Chair - Herman Miller Aeron | Herman Miller | 1 | $1,395.00 | $1,395.00 | Postural support for lumbar region; current chair causes pain after 20 minutes | https://hermanmiller.com/aeron | |
3 | $0.00 | |||||||
4 | $0.00 | |||||||
5 | $0.00 | |||||||
6 | $0.00 | |||||||
7 | $0.00 | |||||||
8 | $0.00 | |||||||
9 | $0.00 | |||||||
10 | $0.00 |
Total Estimated Cost for All Requested Items
Does the total cost exceed $1,000 USD?
Has budget pre-approval been obtained from department head?
Yes - Pre-approved
No - Approval pending
Not applicable - HR budget
Describe alternative solutions you have tried or considered
Rank these items by priority (1 = highest priority)
Primary workstation furniture (desk/chair) | |
Input devices (keyboard/mouse) | |
Visual display equipment (monitors/mounts) | |
Assistive software | |
Environmental controls | |
Mobility/accessibility modifications |
Requested Implementation Date
Does this equipment require professional installation?
Describe installation requirements
Will you require training to use this equipment effectively?
Select preferred training format
One-on-one in-person training
Virtual video training session
Written manuals/guides
Video tutorials
Peer mentoring
This section helps assess the current workstation setup and identify ergonomic risk factors. Please complete honestly and upload supporting photographs where applicable.
Upload current workstation photos (front view, side view, and problem areas)
Rate the ergonomic condition of existing equipment
Office chair adjustability and support | |
Desk height and surface area | |
Monitor position and viewing angle | |
Keyboard and mouse placement | |
Lighting quality and glare control | |
Footrest availability | |
Document holder accessibility | |
Cable management and safety |
Assess environmental comfort factors (1 = Very Poor, 5 = Excellent)
Overall lighting brightness | |
Screen visibility (no glare) | |
Ambient noise level | |
Temperature control | |
Air quality and ventilation | |
Privacy and focus ability | |
Accessibility of shared facilities |
Which postural issues do you experience during work? (Select all that apply)
Forward head posture/neck strain
Rounded shoulders
Lower back pain or pressure
Wrist strain or carpal tunnel symptoms
Eye strain or headaches
Leg discomfort or swelling
Shoulder tension
No significant postural issues
Do you experience pain or discomfort that worsens throughout the workday?
Describe the progression of symptoms and specific triggers
Which virtual/digital ergonomics factors need improvement? (Select all that apply)
Screen reading software compatibility
Voice recognition software needs
Text-to-speech functionality
Screen magnification requirements
Color contrast adjustments
Keyboard shortcut alternatives
Task automation needs
Notification overload
Software interface complexity
Dual monitor configuration
None - digital tools are adequate
How would you rate your current workflow efficiency given your limitations?
Describe any specific tasks that are difficult or impossible to perform with current setup
I confirm that the information provided in this audit accurately reflects my current workstation conditions
This final section is to be completed by HR Business Partner and Environmental Health & Safety (EHS) Lead. It ensures proper review, risk assessment, and formal approval of the accommodation request.
HR Business Partner Name
EHS Lead Name
Review Date
Risk Assessment Matrix
Low Risk | Medium Risk | High Risk | Critical Risk | |
|---|---|---|---|---|
Medical documentation completeness | ||||
Accommodation reasonableness | ||||
Workplace safety impact | ||||
Budget feasibility | ||||
Implementation complexity | ||||
Employee privacy considerations | ||||
Legal compliance risk |
Compliance Verification Checklist
Medical certification verified
Cost estimates validated
Ergonomic audit completed
Alternative solutions considered
Privacy impact assessed
Vendor compliance checked
Insurance implications reviewed
All required signatures obtained
Budget Approval Status
Approved within department budget
Approved from HR central budget
Requires executive approval (> $5,000)
Pending budget allocation
Denied - budget constraints
Provide justification for executive-level budget approval
Explain budget denial and suggest alternative accommodations
Approved Implementation Date
Conditions of Approval or Special Provisions
HR Business Partner Digital Signature
EHS Lead Digital Signature
Final Accommodation Decision
Full Approval - Proceed with procurement
Conditional Approval - See notes
Deferred - Awaiting additional information
Denied - Alternative accommodations recommended
Escalated to Legal/Compliance review
To configure an element, select it on the form.