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Below is a template for an ADA (Americans with Disabilities Act) form that a doctor or healthcare provider might use in a workplace setting. This template provides a structure that can be adapted to specific needs and situations.
A sample form for a health care provider to complete when an employee requests an ADA accommodation.
Get up to speed with the ADA reasonable accommodation and learn how to manage requests. Download our free checklist template and request form for HR!
This template is designed for employees or applicants to formally request accommodations for disabilities as per the Americans with Disabilities Act (ADA) and the Rehabilitation Act, detailing their specific needs, impairment nature, desired accommodations, and necessary medical documentation (employees only).
JAN offers tools that may be useful to employers in the process of requesting medical documentation. See JAN's Medical Inquiry in Response to an Accommodation Request and JAN's Practical Guidance for Medical Professionals: Providing Sufficient Medical Documentation in Support of a Patient's Accommodation Request.
• Accept alternative forms of medical documentation and information (e.g., brief note from primary care provider, or information from a past medical appointment) or
Date: _____________________________________________________________. A sample form for an employee to request an accommodation due to disability.
