This section captures essential employee identification and current work environment details to establish context for the accommodation request. All fields marked mandatory must be completed to ensure proper routing and record-keeping.
Employee ID Number
Full Legal Name
Primary Job Title
Department or Business Unit
Direct Supervisor or Manager Name
Supervisor Email Address
Employment Classification
Full-time Regular
Part-time Regular
Contractor
Temporary Staff
Intern
Original Hire Date
Current Work Arrangement
100% On-site at company facility
100% Remote (home-based)
Hybrid (combination on-site/remote)
Mobile/traveling employee
Primary Work Location Address or Site Name
Workstation Type
Is your workstation in a shared or multi-occupant space?
Employee Work Email
Primary Contact Phone Number
Alternative Contact Number (if applicable)
Have you previously received any workplace accommodations from this organization?
Briefly describe your core job functions that may be impacted by your condition
This section requires official medical documentation to substantiate the accommodation request. All medical information will be handled with strict confidentiality in accordance with organizational privacy policies. Incomplete or undocumented requests cannot be processed.
Nature of Medical Condition or Disability
Physical/Mobility impairment
Sensory impairment (vision/hearing)
Neurological condition
Chronic illness or medical disorder
Mental health condition
Cognitive/learning disability
Temporary injury or recovery
Other condition not listed
Upload Official Physician Medical Certification or Functional Capacity Evaluation
Certifying Healthcare Provider Name
Healthcare Provider License/Registration Number
Healthcare Provider Specialization
Date of Medical Evaluation or Certification
Anticipated Date of Next Medical Review or Re-evaluation
Is this a temporary condition expected to improve with treatment or time?
Rate the severity of functional limitations across key work activity domains. Scale: 1 = No limitation, 5 = Complete inability to perform
Functional Work Limitations Assessment Matrix
Sitting for extended periods (2+ hours continuously) | |
Standing or walking for extended periods | |
Keyboarding, typing, or fine motor hand movements | |
Lifting, carrying, or manual handling of objects | |
Reaching overhead or accessing high storage | |
Vision-intensive tasks (screen work, reading documents) | |
Hearing-dependent tasks (calls, meetings, alerts) | |
Cognitive tasks requiring concentration or memory | |
Interpersonal interaction and communication | |
Adapting to changes in routine or environment |
Describe specific work tasks that are currently difficult or impossible to perform without accommodation
Physician's specific recommendations for workplace accommodations or assistive technology
Does your healthcare provider recommend a phased return-to-work or modified duty schedule?
I authorize my healthcare provider to be contacted for clarification of this certification if required by the organization
Do you require this medical information to be kept completely separate from your general personnel file?
Provide detailed specifications for all requested accommodations, equipment, or workstation modifications. Include vendor quotes where available. This section enables accurate budget forecasting and procurement planning.
Categories of Accommodation Requested (select all that apply)
Assistive Technology (Software/Hardware)
Ergonomic Furniture & Equipment
Workstation Structural Modifications
Alternative Work Schedule or Location
Communication Access Services
Environmental Modifications (Lighting, Sound)
Personal Assistive Devices
Other Specialized Equipment
Itemized Accommodation Request & Cost Breakdown
Select Item for Request | Item Description & Model Number | Category | Unit Cost | Quantity Required | Extended Subtotal | Preferred Vendor Name | Medical/Functional Justification | |
|---|---|---|---|---|---|---|---|---|
Electric Height-Adjustable Desk - Uplift V2 60x30 | Ergonomic Furniture | $650.00 | 1 | $650.00 | Uplift Desk | Essential for alternating sit/stand per medical recommendation | ||
Ergonomic Office Chair - Herman Miller Aeron Size B | Ergonomic Furniture | $1,395.00 | 1 | $0.00 | Herman Miller | Lumbar support for chronic back condition | ||
Dragon Professional Individual v16 Speech Recognition | Assistive Software | $300.00 | 1 | $300.00 | Nuance Communications | Reduces keyboarding strain on wrists | ||
Large Print Keyboard with High Contrast Keys | Assistive Device | $85.00 | 1 | $0.00 | AdaptiKeys | Vision accommodation - pending evaluation | ||
$0.00 | ||||||||
$0.00 | ||||||||
$0.00 | ||||||||
$0.00 | ||||||||
$0.00 | ||||||||
$0.00 |
Upload Vendor Quotes or Product Specifications (optional but recommended for items over $500)
Total Estimated Cost for All Selected Items
Requested Implementation or Delivery Date
Is this request urgent due to immediate medical necessity or safety concerns?
Describe how each requested item will specifically improve your ability to perform essential job functions
What alternative accommodations or lower-cost solutions have you considered or tried? Why are they insufficient?
Will specialized training be required to use the requested equipment or technology effectively?
Estimated Productivity Improvement (percentage) Expected from Accommodations
Additional Notes or Special Installation Requirements
This section assesses the practical feasibility of implementing requested accommodations within the existing workspace infrastructure. Facilities and IT teams will evaluate safety, compliance, and technical compatibility.
Will the accommodation require physical modifications to the building structure, electrical systems, or network infrastructure?
Upload Current Workstation Photos (minimum 3 angles: front, side, wide view)
Detailed description of current workstation dimensions, layout, and surrounding environment
Is there sufficient space to accommodate the requested equipment without creating safety hazards or blocking egress routes?
Safety & Ergonomic Risk Assessment for Proposed Modifications
No Risk | Low Risk | Moderate Risk | High Risk | Critical Risk | |
|---|---|---|---|---|---|
Trip or fall hazards from new equipment placement | |||||
Electrical overload or fire risk from additional devices | |||||
Ergonomic risk if equipment is not properly adjusted | |||||
Blocked emergency exits or accessibility routes | |||||
Increased noise levels affecting nearby workers | |||||
Visual obstruction or line-of-sight safety issues | |||||
Chemical or material handling safety (if applicable) |
Will the accommodation require IT security review or network access changes?
Are there any potential impacts on adjacent coworkers or shared workspace dynamics?
Facility-Specific Requirements or Building Code Considerations
Has a site visit or in-person assessment been conducted by facilities management?
Installation Logistics: Preferred installation timeframe, access requirements, and any special coordination needs
Will ongoing maintenance or technical support be required after installation?
Final authorization section for HR Business Partners and Facilities Leadership to document review, approval decisions, and implementation commitments. All sign-offs must be completed before procurement begins.
HR Intake Received Date
Assigned HR Business Partner Name
HR Business Partner Employee ID
HR Review: Does this request meet organizational policy criteria for reasonable accommodation?
Budget Approval: Is funding available within departmental or centralized accommodation budget?
HR Recommendation Status
Full Approval - Proceed with procurement
Conditional Approval - Pending clarifications noted
Deferred - Requires additional medical documentation
Alternative Solution Recommended - See notes
Denied - Does not meet policy criteria
Facilities Lead Reviewer Name
Facilities Lead Employee ID
Facilities Assessment: Are all physical and technical requirements feasible and code-compliant?
Risk Management Review: Have all safety and liability concerns been addressed?
Approved Implementation or Delivery Date
Implementation Notes and Special Conditions
HR Business Partner Digital Signature & Approval
Facilities Lead Digital Signature & Technical Approval
Does this accommodation require executive leadership approval due to cost or complexity?
Post-Implementation Follow-up Review Date (typically 30-90 days after deployment)
Documentation Storage Location and Record Retention Notes
I confirm that all information provided in this intake evaluation has been reviewed for accuracy and completeness