This section captures essential employee identification and organizational context to ensure proper routing and record-keeping for the accommodation request.
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
Full-time Permanent
Part-time Permanent
Fixed-term Contract
Temporary Assignment
Consultant/Contractor
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
This section documents medical professional validation and specific functional limitations that necessitate workplace accommodations. All medical information will be handled with strict confidentiality.
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?
Nature of Functional Limitations (select all that apply)
Mobility and Ambulation
Fine Motor Skills and Dexterity
Vision and Visual Processing
Hearing and Auditory Processing
Cognitive and Concentration
Respiratory and Environmental Sensitivities
Neurological and Seizure-related
Psychological and Mental Health
Chronic Pain and Fatigue
Other (specify below)
Detailed Description of Workplace Functional Limitations
Specific Work-Related Activities That Are Challenging
Does the condition require periodic rest breaks or modified work schedules?
Are there any emergency medical considerations HR should be aware of?
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
This section details specific equipment, furniture, and structural modifications requested to enable successful performance of essential job functions in the corporate office environment.
Do you require specialized ergonomic furniture or equipment?
Do you require assistive technology or software accommodations?
Do you require modifications to your physical workspace structure?
Do you require changes to meeting room or collaborative space access?
Detailed Equipment and Modification Request Log
Item/Modification Description | Justification/Medical Need | Estimated Cost (USD) | Requested Implementation Date | Priority Level | Is this a temporary or permanent need? | |
|---|---|---|---|---|---|---|
If specific products or vendors are preferred, provide details and rationale:
Have you previously used similar accommodations in a remote work setting?
Are you willing to participate in a trial period with temporary equipment before permanent procurement?
This section evaluates workplace safety, emergency preparedness, and comprehensive accessibility needs to ensure a secure and inclusive office environment.
Do you require a personal emergency evacuation plan (PEEP)?
Are there accessibility barriers in your planned office location?
Do you have specific sensory or environmental sensitivities?
Rate the current accessibility and ergonomic status of proposed workspace elements
Completely Inadequate | Mostly Inadequate | Partially Adequate | Mostly Adequate | Completely Adequate | |
|---|---|---|---|---|---|
Desk height and adjustability | |||||
Chair support and customization | |||||
Monitor positioning and visibility | |||||
Keyboard and mouse placement | |||||
Lighting adequacy and adjustability | |||||
Pathway clearance and maneuverability | |||||
Proximity to essential facilities | |||||
Noise level and acoustic environment | |||||
Temperature and ventilation control | |||||
Emergency egress routes |
Do you require accessible parking provisions?
Will you require assistance with office navigation or wayfinding?
Do you have dietary restrictions related to medical conditions that affect cafeteria or catering access?
Describe any additional safety concerns or accessibility needs not covered above:
Have you reviewed the corporate office accessibility map and facilities guide?
This final section captures formal review, risk assessment, budget approval, and authorization from designated HR leadership. All decisions must be documented with clear rationale.
Workplace Experience Lead Reviewer Name
Workplace Experience Review Date and Time
Has the Workplace Experience Lead verified all medical documentation is complete and valid?
Have all requested accommodations been physically verified as feasible in the proposed workspace?
Total Estimated Cost of All Accommodations (Equipment + Modifications + Services)
Budget Approval Status
Approved within departmental budget
Requires executive budget exception
Pending finance review
Denied based on cost constraints
Are there any identified risks or liabilities associated with granting these accommodations?
HR Director Approver Name
HR Director Approval Date and Time
Final Accommodation Decision
Fully Approved as Requested
Conditionally Approved with Modifications
Partially Approved (some requests denied)
Denied (no reasonable accommodation identified)
Deferred Pending Additional Information
Detailed Approval Conditions or Alternative Accommodations Offered
Accommodation Implementation Target Date
Does this accommodation require periodic review or have an expiration 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