Comprehensive Accommodation Assessment for Hybrid Workforce Transition

Employee Full Legal Name

Employee ID Number

Official Job Title

Primary Department

Direct Manager Full Name

Manager Employee ID

Work Email Address

Direct Phone Extension

Original Hire Date

Current Role Start Date

Employment Classification

Describe Current Hybrid Work Arrangement

Average Days per Week in Corporate Office (pre-request)

Proposed Return-to-Office Start Date

Primary Corporate Location/Building Name

Preferred Work Floor or Zone (if applicable)

Emergency Contact Information

Certifying Medical Professional Full Name

Medical Professional License/Registration Number

Medical Professional Specialty

Medical Institution/Practice Name

Medical Evaluation Date

Medical Certification Valid Until

Upload Official Medical Certification Document

Is this a temporary or permanent condition/limitation?

Specify expected duration and recovery timeline:

Provide details on permanence and long-term management considerations:

Nature of Functional Limitations (select all that apply)

Detailed Description of Workplace Functional Limitations

Specific Work-Related Activities That Are Challenging

Does the condition require periodic rest breaks or modified work schedules?

Specify recommended frequency and duration of breaks or schedule modifications:

Are there any emergency medical considerations HR should be aware of?

Describe emergency protocols, warning signs, and required immediate actions:

I consent to HR consulting with the medical provider for clarification purposes only

I understand that this information will be stored securely and accessed only by authorized HR personnel

Do you require specialized ergonomic furniture or equipment?

Select all requested ergonomic equipment:

Do you require assistive technology or software accommodations?

Select all requested assistive technologies:

Do you require modifications to your physical workspace structure?

Select all requested structural adjustments:

Do you require changes to meeting room or collaborative space access?

Select meeting space accommodations needed:

Detailed Equipment and Modification Request Log

If specific products or vendors are preferred, provide details and rationale:

Have you previously used similar accommodations in a remote work setting?

Describe what worked well and what requires improvement for the office environment:

Are you willing to participate in a trial period with temporary equipment before permanent procurement?

Do you require a personal emergency evacuation plan (PEEP)?

Select required emergency evacuation accommodations:

Are there accessibility barriers in your planned office location?

Identify all accessibility barriers that need remediation:

Do you have specific sensory or environmental sensitivities?

Select environmental accommodations needed:

Rate the current accessibility and ergonomic status of proposed workspace elements

Do you require accessible parking provisions?

Specify parking location preferences, distance tolerance, and any permit requirements:

Will you require assistance with office navigation or wayfinding?

Select preferred navigation support method:

Do you have dietary restrictions related to medical conditions that affect cafeteria or catering access?

Describe dietary requirements and necessary food service accommodations:

Describe any additional safety concerns or accessibility needs not covered above:

Have you reviewed the corporate office accessibility map and facilities guide?

Workplace Experience Lead Reviewer Name

Workplace Experience Review Date and Time

Has the Workplace Experience Lead verified all medical documentation is complete and valid?

Specify what documentation is missing or requires follow-up:

Have all requested accommodations been physically verified as feasible in the proposed workspace?

Describe feasibility concerns or alternative workspace suggestions:

Total Estimated Cost of All Accommodations (Equipment + Modifications + Services)

Budget Approval Status

Provide justification for budget exception and route to executive leadership:

Specify finance review timeline and outstanding questions:

Explain cost constraint rationale and propose lower-cost alternatives:

Are there any identified risks or liabilities associated with granting these accommodations?

Describe risk mitigation strategies and contingency plans:

HR Director Approver Name

HR Director Approval Date and Time

Final Accommodation Decision

Detailed Approval Conditions or Alternative Accommodations Offered

Accommodation Implementation Target Date

Does this accommodation require periodic review or have an expiration date?

Next Scheduled Review Date:

Employee Communication Plan and Training Requirements

Has the employee been informed of their right to appeal this decision?

Upload Signed Accommodation Agreement Form

HR Director Digital Signature

Workplace Experience Lead Digital Signature

Employee Acknowledgment Signature