This section captures essential employee identification and workplace location details to establish the request context and ensure proper routing for evaluation and implementation.
Employee Full Legal Name
Employee Unique Identifier
Official Company Email Address
Department or Business Division
Engineering & Technology
Sales & Marketing
Finance & Accounting
Human Resources
Legal & Compliance
Operations
Customer Support
Research & Development
Other
Job Title or Role
Employment Classification
Full-Time Permanent
Full-Time Contract
Part-Time Permanent
Part-Time Contract
Intern
Apprentice
Consultant
Direct Manager Full Name
Direct Manager Email Address
Current Primary Work Arrangement
Fully Remote
Hybrid (2-3 days/week on-site)
Hybrid (4+ days/week on-site)
Fully On-Site
Currently on Leave
Expected Return-to-Office Date
Primary Office Location
Corporate Headquarters
Regional Office - North
Regional Office - South
Regional Office - East
Regional Office - West
Satellite Office
Co-working Space
Other
Building Name or Identifier
Floor Number
Current Desk or Workstation Identifier
Nearest Emergency Exit or Stairwell Identifier
Preferred Communication Methods for Accommodation Updates
Company Email
Personal Email
Phone Call
Text Message
Manager Relay
HR Portal Notification
Emergency Contact Person Full Name
Emergency Contact Relationship
Emergency Contact Phone Number
Employee Time Zone for Coordination
Provide comprehensive medical certification details and specific workstation restrictions. All information will be handled confidentially in accordance with privacy policies. Medical documentation must be uploaded to support this request.
Primary Medical Condition Category
Musculoskeletal Disorder
Neurological Condition
Sensory Impairment
Respiratory Condition
Cardiovascular Condition
Mental Health Condition
Autoimmune Disorder
Chronic Pain Condition
Other
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
Temporary (less than 6 months)
Temporary (6-12 months)
Temporary (1-2 years)
Permanent/Chronic Condition
Recommended Review Date for Temporary Conditions
Do you have restrictions on continuous sitting duration?
Do you have restrictions on continuous standing duration?
Is a height-adjustable or sit-stand workstation medically necessary?
Do you have specific lighting sensitivity or requirements?
Do you have specific noise sensitivity or acoustic requirements?
Do you have temperature sensitivity or environmental control needs?
Is an accessible pathway or modified office layout required for mobility?
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?
Detail all requested accommodations and equipment specifications. Provide as much technical detail as possible to facilitate procurement and installation. Include justification for each item to support the business case.
Categories of Accommodation Requested
Ergonomic Furniture & Seating
Assistive Technology Devices
Environmental Control Modifications
Workspace Reconfiguration
Mobility & Accessibility Equipment
Specialized Computer Peripherals
Other
Ergonomic Furniture & Seating Specifications
Item Description | Quantity Required | Required Dimensions (HxWxD cm) | Preferred Brand/Model (if any) | Estimated Unit Cost | Total Item Cost | Medical Justification & Business Need | |
|---|---|---|---|---|---|---|---|
Height-adjustable desk | 1 | 72-120 x 140 x 80 | Varidesk Pro Plus | $450.00 | $450.00 | Required for alternating between sitting and standing due to spinal stenosis | |
Ergonomic office chair with lumbar support | 1 | 120-130 x 65 x 65 | Herman Miller Aeron | $1,200.00 | $1,200.00 | Medical necessity for chronic lower back pain and postural support | |
Footrest with adjustable height | 1 | 15-25 x 50 x 30 | 3M Adjustable Footrest | $75.00 | $75.00 | Reduces pressure on lower back and improves circulation | |
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$0.00 |
Assistive Technology & Specialized Equipment
Device Type | Quantity | Technical Specifications | Compatibility Requirements | Estimated Cost | Purpose and Justification | |
|---|---|---|---|---|---|---|
Large-format monitor (27+ inch) | 2 | 4K resolution, anti-glare | USB-C, Mac/Windows | $800.00 | 1600 | |
Ergonomic split keyboard | 1 | Mechanical, programmable keys | USB/Bluetooth, multi-OS | $150.00 | 150 | |
Vertical ergonomic mouse | 1 | Adjustable DPI, left-hand option | Wireless USB receiver | $95.00 | 95 | |
Detailed Description of Workspace Reconfiguration Needs
Alternative Solutions or Equipment Already Considered
Requested Installation or Implementation Date
Urgency Level for This Accommodation
Critical - Required for immediate return to prevent health deterioration
High - Required within 2 weeks of return date
Medium - Required within 1 month of return date
Low - Can be implemented within 2-3 months
Will this equipment be shared with other employees or used exclusively by you?
Do you require training to properly use the requested equipment?
Will this accommodation require IT support or infrastructure changes?
Yes - Requires network, software, or hardware integration
No - Standalone equipment
Maybe - Uncertain about technical requirements
This section must be completed by Facilities Management or designated workplace assessor. It evaluates the physical feasibility, safety compliance, and implementation requirements for the requested accommodations.
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?
Is network data port available or can wireless connectivity support all equipment?
Will structural modifications be required (walls, flooring, ceiling, permanent fixtures)?
Will this accommodation impact HVAC, air circulation, or temperature control for this zone?
Does this accommodation comply with fire safety codes and emergency evacuation protocols?
Is the accessible pathway clearance maintained per accessibility standards?
Will this accommodation impact adjacent workstations or shared spaces?
Implementation Complexity Assessment
Simple - Plug-and-play equipment, no modifications
Moderate - Minor setup, possible furniture reconfiguration
Complex - Requires electrical/data work, space planning
Major Renovation - Structural changes, permits, specialized contractors
Estimated Implementation Timeline in Business Days
Total Estimated Implementation Cost
Recommended Funding Source
Department Operating Budget
Facilities Capital Budget
HR Accommodation Fund
Employee Insurance Claim
Workers Compensation
Corporate ESG Fund
Other
Risk Assessment Score (1=Minimal Risk, 5=High Risk)
Is an alternative workspace available if primary accommodation cannot be implemented?
Vendor or Supplier Requirements
Ongoing Maintenance and Support Requirements
Feasibility Assessment Matrix
Not Feasible | Major Challenges | Moderate Challenges | Minor Issues | Fully Feasible | |
|---|---|---|---|---|---|
Space availability | |||||
Infrastructure compatibility | |||||
Budget availability | |||||
Timeline feasibility | |||||
Regulatory compliance | |||||
Safety standards |
Final review and approval section. All parties must confirm their assessment and authorization before implementation proceeds. Incomplete approvals will delay the accommodation process.
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?
Have alternative accommodations been considered and offered to the employee?
Has the employee accepted the final accommodation offer?
Is budget approved for this accommodation?
Facilities Manager Name
Facilities Review Completion Date
Technical feasibility confirmed and implementation plan established?
Implementation timeline approved and resources allocated?
Safety compliance and risk mitigation measures verified?
Final Approval Status
Approved - Proceed with implementation
Approved with Conditions - See notes
Deferred - Pending additional information
Denied - Undue hardship or infeasibility
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