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Reasonable Accommodation Request Form

A reasonable accommodation request form for ADA, PWFA, and religious requests: employee section, interactive-process log, medical questions, and decision.

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What you get

An employee request section that works for disability, pregnancy-related, and religious accommodations
An interactive-process log to document every conversation, option considered, and outcome
A limited medical documentation request that asks only for what the decision needs
A decision section covering approval, alternative accommodation, and denial with undue-hardship reasoning
A summary of ADA, PWFA, Title VII after Groff v. DeJoy, and state laws that reach smaller employers

Template preview

A preview of the structure. Download the PDF or CSV for the complete, ready-to-use version.

Requests don't require magic words or this form. A verbal request to a manager counts, and so does a request made by a family member or doctor on the employee's behalf. This form is for documenting the process, not a gate the employee must pass through before you act.

Part 1: Employee request

Employee name, job title, department
Manager name
Date request first made, and to whom— this is the start date, even if the form is filled in later
Type of request— disability (ADA) / pregnancy, childbirth, or related condition (PWFA) / religious belief or practice / other

Part 2: Interactive process log

Record every meeting, call, or email. Courts look at whether the employer engaged in good faith, and this log is the evidence.

Date	Participants	Discussed / options raised	Outcome or next step	Owner
2026-09-02	Employee, HR (L. Kim)	Needs to avoid lifting over 20 lb for 3 months; asked about light duty	HR to check which tasks involve lifting	L. Kim
2026-09-05	Employee, HR, manager	Reviewed task list; option of reassigning pallet moves to teammate	Trial for 2 weeks from 2026-09-08	Manager

Part 3: Medical documentation request (only if needed)

Ask for documentation only when the disability or need for accommodation isn't obvious or already known. Limit the request to what you need to decide: whether the employee has a condition covered by the law, the functional limitations, and how the requested accommodation would help. Don't ask for a diagnosis if the limitation alone answers the question, and don't request complete medical records. Under the EEOC's PWFA rule, documentation generally shouldn't be requested for obvious pregnancy-related needs such as extra bathroom, food, or water breaks, carrying water, or sitting or standing as needed.

Health care provider questionnaire

Provider name, credentials, and contact
Does the employee have a physical or mental condition that limits a major life activity or bodily function?— yes / no; diagnosis not required
Functional limitations relevant to the job— attach the job description
Expected duration of the limitations

This is a preview — the full template continues in the download.

How to use this template

1
Start the process as soon as a need is raised
An employee doesn't need to use the words "reasonable accommodation" or fill in this form. Once they tell a manager or HR they need a change at work because of a medical condition, pregnancy, or religious practice, the process has started.
2
Have the conversation, then document it
Meet with the employee to understand the limitation or practice and the job tasks affected. Use the form to record what was requested and discussed, not as a hurdle they must clear first.
3
Request documentation only if you need it
If the disability or need isn't obvious, you can ask for limited information from a health care provider. Many pregnancy-related and religious requests need no documentation at all.
4
Explore options and log each one
Record every accommodation considered, who suggested it, and why it was or wasn't workable. The employer chooses among effective options, but should give weight to the employee's preference.
5
Decide in writing and set a review date
Give a written decision, and if you deny or offer an alternative, explain the reason. Set a follow-up date to check the accommodation is working.

Frequently asked questions

Does an employee have to fill out a form to request an accommodation?

No. Under the ADA and PWFA, a request can be verbal, informal, and made in plain language, such as "I'm having trouble standing all day because of my back." Refusing to act until a form is completed can itself be a failure to accommodate. Use the form to document the request after it's made.

Can an employer ask for a doctor's note for an accommodation?

Yes, when the disability or need isn't obvious, but the request must be limited to what's needed to confirm the condition and the need for accommodation. You can't ask for complete medical records. For many pregnancy-related requests, the EEOC's PWFA rule says documentation generally shouldn't be required.

What counts as undue hardship for religious accommodation after Groff v. DeJoy?

The employer must show that the accommodation would result in substantial increased costs in relation to the conduct of its particular business. That's a much higher bar than the old "more than de minimis" standard many employers relied on. Considering voluntary shift swaps and other options before denying is now expected.

Does the employer have to give the exact accommodation requested?

No. The employer can choose among effective accommodations and may pick the less expensive one. The alternative must actually remove the barrier, and the employee's preference should be considered in good faith. Document why the chosen option works.

What is the interactive process?

It's the informal back-and-forth between employer and employee to identify the limitation and find an effective accommodation. It isn't a single meeting — it continues until a workable solution is found or it's clear none exists. Failing to engage in good faith is a common reason employers lose accommodation claims.

Do small employers have to provide accommodations?

The ADA, PWFA, and Title VII apply to employers with 15 or more employees, but many state and local laws cover smaller businesses. California's threshold is 5 employees, and New York State's law covers employers of any size. Check the law where the employee works.