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Free Reasonable Accommodation Request Form

Employees can ask for a change at work because of a disability or a pregnancy-related limitation. This form starts the "interactive process" the EEOC describes, and asks only for what you need to know — never for a diagnosis or family medical history.

Download free (Word .docx) Free · No sign-up · Opens in Microsoft Word and Google Docs · Last reviewed October 2026

Important: please read

This template is a free starting point, not legal advice. MadyHR.ai is not a law firm and cannot give legal advice. Employment law is different in every state, and some cities have their own rules. Laws also change. Before you use this template, check it against the laws where your employees work, and speak to an employment attorney or your state labor department if you are unsure. You use this template at your own risk, and MadyHR.ai accepts no responsibility for how it is used. Links to official government websites are given for information only; MadyHR.ai is not affiliated with or endorsed by any government agency.

When to use this template

  • An employee asks for a change because of a medical condition
  • A pregnant employee needs an adjustment
  • Documenting the interactive process

Tips before you use it

  • An employee does not have to use this form or any special words to ask for an accommodation — treat any request as a request.
  • Only ask for medical documentation when the disability or need is not obvious, and only what is needed.
  • Under the Pregnant Workers Fairness Act, many simple accommodations (like extra water breaks) should not require medical documentation.
  • Keep medical information confidential and separate from the personnel file.
  • Many state laws protect smaller employers' staff too, or require extra accommodations — check your state's fair employment agency.
Rules in your state may differ. Federal law sets the minimum. Your state — and sometimes your city or county — may add extra rules on this topic. Check with your state labor department before you use this template. Find your state labor office (U.S. Department of Labor)

Template preview

Replace everything in [brackets] and delete the notes for employers before you use it. The Word download contains the full template.

[Company Name]

Reasonable Accommodation Request Form

Part 1: Employee request

Employee name: [Employee Name]

Job title: [Job Title]

Manager: [Manager Name]

Date: [Date]

What job tasks or workplace rules are difficult for you because of a medical condition or a pregnancy-related limitation?
What change, equipment or adjustment are you asking for?
How will this help you do your job?
Is this temporary? If so, for how long?

You do not need to give a diagnosis on this form.

Employee
Signature
Date

Part 2: Interactive process (employer use)

DateDiscussion / options consideredWho attended
Medical documentation requested? (only if the need is not obvious) — Y/N and why

Genetic information notice

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic information," as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Part 3: Decision

  • Accommodation approved as requested
  • Alternative effective accommodation offered
  • Request denied (explain below)
Accommodation details
Start date
Review date (if any)
Reason if denied or changed
For [Company Name]
Signature
Date
Employee
Signature
Date

Note for employer (delete before use): Store this form and any medical records in a confidential file, separate from the personnel file.

Download free (Word .docx)

Frequently asked questions

Do employees have to put accommodation requests in writing?

No. An employee can request an accommodation verbally and in plain language. A form like this helps document the request, but you cannot refuse to consider a request because the form was not used.

What is the GINA safe-harbor notice?

Language from the federal GINA regulations that employers can include when requesting medical information, telling the employee and their doctor not to provide genetic information. It helps protect the employer if genetic information is received inadvertently.

Official sources

Each source below is an official U.S. government website. Check them for the latest rules.

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