Employee Accommodation Request Form Template
This employee accommodation request form helps someone describe a work barrier, suggest an adjustment, and explain how they would like to discuss it. Use the seven optional fields to prepare a focused conversation with the person responsible for workplace adjustments.
This employee accommodation request form helps someone describe a work barrier, suggest an adjustment, and explain how they would like to discuss it. Use the seven optional fields to prepare a focused conversation with the person responsible for workplace adjustments.
An employee may know which task is difficult without knowing the right solution. Leave room for that uncertainty. SurveyLegend provides a starting questionnaire you can adapt to the organization’s actual request process, with an alternative contact route for people who cannot or prefer not to use a form.
When to Use This Template
Use this form at the start of an adjustment conversation, before a solution is selected. It gathers practical context about tasks, barriers and communication preferences. Broader employee surveys serve different purposes; an individual request needs a named reviewer and an actual follow-up process.
7 Employee Accommodation Request Form Questions
Describe the work change you want to discuss. Every question is optional. Leave out diagnoses, medical documents and other people's private information. This example does not submit a request to an employer. For an actual request, use your organization's stated contact route.
A little feedback. A clearer picture.
Explore this 7-question example at your own pace. Every question is optional.
Employee Accommodation Request Form
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How to Adapt the Questionnaire
Name the reviewing team, explain who can read the request, and describe how someone can contact that team without the form. Replace timing choices only when the team can handle them. Do not require someone to identify a diagnosis or select a perfect adjustment before starting a conversation. Review the actual collection process before promising confidentiality; SurveyLegend’s discussion of sensitive questions explains why that promise must match reality.
When to Ask
Offer the form whenever an employee wants to raise a current barrier or prepare for a known change. Do not restrict it to annual reviews. Check incoming requests through the organization's established process, and agree on the next conversation directly rather than treating the selected timing as a guaranteed appointment.
How to Use the Responses
Read the task, barrier and proposed adjustment together. A request for equipment may reveal a communication or workflow issue, so confirm what the employee wants to accomplish before deciding on a response. Keep case handling separate from aggregate reporting, limit access to those involved, and avoid publishing small groups that could identify requesters. A blank field is a topic to clarify respectfully, not evidence that no adjustment is needed.
What the Research Adds
Davies and colleagues (2022) surveyed 181 autistic adults in the UK. Their abstract describes difficulties with having to “establish the specific adjustments that would be beneficial.” This supports leaving room for someone to request a discussion without naming a solution. Read the workplace adjustment study . Its findings concern that study population; they do not validate this form or determine an employer’s obligations.
Frequently asked questions
Does an employee need to suggest a solution?
No. The form includes an option for help identifying an adjustment. A useful first step can be explaining the task and what gets in the way.
Does submitting the form approve an adjustment?
No. The organization must review and discuss a request through its actual process. The public example does not send anything to an employer.
Should this form collect medical evidence?
This starting version does not. If additional information is needed, the responsible team should use its approved process and explain what is necessary and why.
Printable Employee Accommodation Request Form
Offer the same seven fields on paper with generous space for the task, barrier and proposed change. Specify the actual designated recipient and a private return method before distribution. Do not leave completed copies in a shared collection tray. Paper responses need separate review or manual entry; they are not automatically added to online results.
Download the questionnaire AI Prompt: Employee Accommodation Request Form
Copy this employee accommodation request form prompt into an AI assistant to prepare the questionnaire. Review the result, then build and customize it in SurveyLegend. It does not automatically create or transfer a survey.
Employee Accommodation Request Form Prompt
Copy the prompt into an AI assistant to draft the questions, then build your survey in SurveyLegend.
Sign in to SurveyLegend to build your employee accommodation request form
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