(To be completed by HR / Accommodation Specialist upon opening case)
Employee Name
Employee ID #
Job Title / Position
Department / Division
Direct Supervisor
Case Reference #
Date Initial Request Received
Intake Method
Written Request Form
Verbal Request
Medical Note Received
Third-Party Referral
(Summarize the verified functional limitations based on medical documentation)
Medical Documentation Status
Sufficient documentation received on file
Additional medical clarification requested from provider
Medical documentation waived (e.g., obvious or previously documented impairment)
Expected Duration of Impairment
Temporary
Permanent / Chronic
Fluctuating / Episodic (e.g., flare-ups requiring intermittent accommodation)
Estimated End Date
Physical Capabilities
No limitations identified
Limited physical capacity
Detailed Restrictions (e.g., max lift 10 lbs, no repetitive bending, posture limits)
Schedule & Work Environment
No limitations identified
Limited schedule / environmental tolerance
Detailed Restrictions (e.g., capped hours, specialized lighting, noise limits)
Cognitive & Task Execution
No limitations identified
Limited cognitive / focus capacity
Detailed Restrictions (e.g., written vs. verbal instructions, single-tasking directives)
(HR and Manager identify core duties to ensure accommodations support essential functions without removing primary job responsibilities)
Duty Description | Essential | Marginal | Impacted by Limitation? | Accommodation Feasible? | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | ||||||
2 | ||||||
3 | ||||||
4 | ||||||
5 |
(Document all direct discussions held with the employee to explore viable accommodations)
Date
Attendees
Key Solutions Requested by Employee
Employer Suggestions / Alternatives Proposed
Date
Attendees
Review of Proposed Solutions / Department Feedback
Agreed Action Items / Next Steps
(Assess primary options discussed during the interactive dialogue)
Option 1 (Employee Preferred)
Feasibility Status
Viable
Not Viable
Assessment / Operational Notes
Option 2 (Alternative Solution A)
Feasibility Status
Viable
Not Viable
Assessment / Operational Notes
Option 3 (Alternative Solution B)
Feasibility Status
Viable
Not Viable
Assessment / Operational Notes
APPROVED — Requested Accommodation: Full approval of the employee's preferred accommodation.
APPROVED — Alternative Accommodation: Approval of an effective alternative accommodation identified during the interactive process.
DENIED — Reassignment Exploration Triggered: No accommodation is feasible in the current role; exploring vacant position reassignment.
DENIED — Unable to Accommodate: Accommodations present significant operational disruption or remove essential job functions.
Specific Accommodation(s) to be Provided
Effective Start Date
Target Review Date (30 / 60 / 90 Days)
Responsible Party for Equipment / Setup Purchase
By signing below, the undersigned confirm that they engaged in an interactive process to explore reasonable workplace accommodations in good faith.
Signature
Signature
Signature
Form Template Insights
Please remove this form template insights section before publishing.
Every section and question within this form plays a distinct role in structuring communications, establishing facts, and arriving at a workable workplace solution. Here is a section-by-section breakdown detailing why each specific entry is necessary for HR teams.
Why these questions are necessary:
This section establishes administrative ownership, tracks response timelines, and captures essential organizational metadata.
Why these questions are necessary:
This section grounds the interactive dialogue in objective facts provided by treating healthcare professionals, avoiding assumptions or subjective interpretations.
Why these questions are necessary:
This analysis is the operational core of accommodation management.
Why these questions are necessary:
A successful accommodation process relies on active, ongoing dialogue between the employee, HR, and department management.
Why these questions are necessary:
Rarely is there only one way to accommodate a workplace barrier. Evaluating multiple options ensures thorough decision-making.
Why these questions are necessary:
This section converts discussion into action, setting clear expectations for implementation and ongoing review.
Why these questions are necessary:
Signatures certify that the evaluation process was completed thoroughly, transparently, and collaboratively.
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation section before publishing.
When configuring the Employee Reasonable Accommodation Interactive Process Summary & Determination Form, the following questions must be set as mandatory to ensure fair evaluations, prevent miscommunications, and maintain smooth workplace operations:
To configure an element, select it on the form.