Comprehensive Evaluation for Workplace Medical Accommodations & Specialized Equipment Requests

Employee Full Legal Name

Employee Unique Identifier

Official Company Email Address

Department or Business Division

Please specify your department

Job Title or Role

Employment Classification

Direct Manager Full Name

Direct Manager Email Address

Current Primary Work Arrangement

Please provide details about your current leave status

Expected Return-to-Office Date

Primary Office Location

Please specify office location

Building Name or Identifier

Floor Number

Current Desk or Workstation Identifier

Nearest Emergency Exit or Stairwell Identifier

Preferred Communication Methods for Accommodation Updates

Emergency Contact Person Full Name

Emergency Contact Relationship

Emergency Contact Phone Number

Employee Time Zone for Coordination

Primary Medical Condition Category

Please describe your medical condition in detail

Specific Diagnosis or Functional Limitations Description

Primary Healthcare Provider Name

Healthcare Provider Credentials or Medical Specialty

Date of Most Recent Medical Evaluation

Medical Certification Validity Period

Expected Duration in Months

Expected Duration in Months

Expected Duration in Months

Recommended Review Date for Temporary Conditions

Do you have restrictions on continuous sitting duration?

Please specify maximum sitting duration and required break frequency (e.g., 30 minutes sitting, 5-minute standing break every hour)

Do you have restrictions on continuous standing duration?

Please specify maximum standing duration and required rest intervals

Is a height-adjustable or sit-stand workstation medically necessary?

Describe specific height adjustment range or mechanism requirements

Do you have specific lighting sensitivity or requirements?

Select all lighting accommodations needed

Do you have specific noise sensitivity or acoustic requirements?

Select all acoustic accommodations needed

Do you have temperature sensitivity or environmental control needs?

Describe specific temperature ranges, airflow, or humidity requirements

Is an accessible pathway or modified office layout required for mobility?

Describe pathway width requirements, turning radius, or furniture clearance needs

Detailed Description of Functional Limitations Impacting Workstation Use

Upload Primary Medical Certification or Doctor's Recommendation Letter

Upload Additional Supporting Medical Documentation (optional)

Have you previously discussed this accommodation need with your direct manager?

Describe the outcome of that discussion and any preliminary arrangements made

Categories of Accommodation Requested

Ergonomic Furniture & Seating Specifications

Assistive Technology & Specialized Equipment

Detailed Description of Workspace Reconfiguration Needs

Alternative Solutions or Equipment Already Considered

Requested Installation or Implementation Date

Urgency Level for This Accommodation

Will this equipment be shared with other employees or used exclusively by you?

Describe the sharing arrangement and schedule

Do you require training to properly use the requested equipment?

Select all training types needed

Will this accommodation require IT support or infrastructure changes?

Describe required IT support, software installations, network access, or security configurations

Explain your concerns about technical requirements

Workplace Assessor Name

Site Assessment Conducted Date

Current Workstation Footprint Dimensions - Length (cm)

Current Workstation Footprint Dimensions - Width (cm)

Are electrical outlets available within 2 meters of the workstation?

Describe electrical infrastructure work required (new outlets, power strips, extension solutions)

Is network data port available or can wireless connectivity support all equipment?

Describe data infrastructure requirements (cabling, WiFi boosters, network switches)

Will structural modifications be required (walls, flooring, ceiling, permanent fixtures)?

Detail structural changes needed: wall reinforcement, floor anchoring, ceiling mounts, or permanent installations

Will this accommodation impact HVAC, air circulation, or temperature control for this zone?

Describe HVAC modifications needed (individual climate control, air filter upgrades, vent repositioning)

Does this accommodation comply with fire safety codes and emergency evacuation protocols?

Identify fire safety concerns and required mitigation measures

Is the accessible pathway clearance maintained per accessibility standards?

Describe pathway obstruction issues and required space reconfiguration

Will this accommodation impact adjacent workstations or shared spaces?

Describe impact on neighbors (noise, space encroachment, visual barriers) and required coordination

Implementation Complexity Assessment

Estimated Implementation Timeline in Business Days

Total Estimated Implementation Cost

Recommended Funding Source

Risk Assessment Score (1=Minimal Risk, 5=High Risk)

Is an alternative workspace available if primary accommodation cannot be implemented?

Describe alternative workspace location and its suitability

Vendor or Supplier Requirements

Ongoing Maintenance and Support Requirements

Feasibility Assessment Matrix

HR Business Partner Name

HR Review Completion Date

I have reviewed all medical documentation and verify it supports the accommodation request

Is the requested accommodation reasonable and does not impose undue hardship?

Explain the undue hardship factors (cost, fundamental alteration, safety, etc.)

Have alternative accommodations been considered and offered to the employee?

Describe alternative accommodations offered and employee's response

Has the employee accepted the final accommodation offer?

Describe outstanding concerns or negotiations in progress

Is budget approved for this accommodation?

Provide budget approval timeline or alternative funding pathway

Facilities Manager Name

Facilities Review Completion Date

Technical feasibility confirmed and implementation plan established?

Identify technical barriers and required resolution steps

Implementation timeline approved and resources allocated?

Describe resource constraints or scheduling conflicts

Safety compliance and risk mitigation measures verified?

Detail safety concerns and required corrective actions

Final Approval Status

Conditions, Notes, or Additional Actions Required

Target Implementation Completion Date

Employee Acknowledgement Signature

Employee Acceptance Date

HR Business Partner Approval Signature

Facilities Manager Approval Signature

Next Review or Follow-up Date