---
generated_by: surveylegend-page-markdown
title: Employee Accommodation Request Form | SurveyLegend
description: Collect work barriers, adjustment ideas, timing, and contact
  preferences with seven optional fields. Adapt this accommodation request form
  in SurveyLegend.
canonical: https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/employee-accommodation-form-template/
---

# 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.

[Try this template ](https://app.surveylegend.com/register/)[Preview template](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/employee-accommodation-form-template/#try-template)

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Employee Accommodation Request Form

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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 ](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/)serve different purposes; an individual request needs a named reviewer and an actual follow-up process.

**Create your employee accommodation request form in SurveyLegend**

An employee may know which task is difficult without knowing the right solution. Leave room for that uncertainty.

## 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.

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## A little feedback. A clearer picture.

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SurveyLegend demo Question 1 of 7

### Employee Accommodation Request Form

01 What work task or situation would you like to discuss?

Share your answer, or skip this question.

02 What makes that task or situation difficult in the current setup?

Share your answer, or skip this question.

03 Which area best describes the change you would like to explore?

Choose one answer, or skip this question.

Workspace or equipment Work schedule Communication or instructions How a task is organized Access to a work activity More than one area I need help identifying an adjustment Another area Prefer not to answer

04 What adjustment, if any, would you like the reviewer to consider?

Share your answer, or skip this question.

05 When would you like to discuss this request?

Choose one answer, or skip this question.

As soon as the review team can contact me Within the next week Within the next month Before a planned work change Timing is flexible Prefer not to answer

06 What would make the follow-up conversation easier for you?

Share your answer, or skip this question.

07 What name and contact route may the designated reviewer use to follow up?

Share your answer, or skip this question.

#### One last look

Review your answers before submitting this demo.

0 answered

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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 ](https://www.surveylegend.com/survey-questions/sensitive-survey-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 ](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0272420). 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.

![First page of the printable Employee Accommodation Request Form Template with questions and answer spaces](https://www.surveylegend.com/survey-template-media/pdf-previews/employee-accommodation-form-template-pdf-preview.avif)

[![](https://www.surveylegend.com/user-guide-media/icons/download-pdf.svg) Download the questionnaire](https://www.surveylegend.com/downloads/survey-templates/employee-accommodation-request-form-template.pdf)

Export Employee Accommodation Request Form as PDF

## 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

AI Prompt: Employee Accommodation Request Form

[Create this survey in SurveyLegend](https://www.surveylegend.com/register/)

Copy the prompt into an AI assistant to draft the questions, then build your survey in SurveyLegend.

[Sign in](https://app.surveylegend.com/) to SurveyLegend to build your employee accommodation request form

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35. [![Preview of the Employee Award Nomination Form Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/employee-award-nomination-form-template-preview.avif) Employee Award Nomination Form Template Employee An employee award nomination form gathers comparable information about one eligible employee for one defined award. A useful form asks who is being nominated, which criterion applies, what the employee did and what evidence the review panel can examine.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/employee-award-nomination-form-template/)
36. [![Preview of the Employee Complaint Form Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/employee-complaint-form-template-preview.avif) Employee Complaint Form Template Employee A complaint may concern a pattern rather than a single date, and the usual manager may not be the right person to receive it. Build the form in SurveyLegend around a clearly explained review route instead of assuming that every concern follows the same path.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/employee-complaint-form-template/)
37. [![Preview of the Employee Safety Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/employee-safety-template-preview.avif) Employee Safety Survey Template Employee A procedure can look clear on paper while employees lack the time or equipment to follow it. This questionnaire gives a team a structured way to identify operational barriers and choose a follow-up. It is for routine feedback, not urgent incident reporting or a formal risk assessment.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/employee-safety-template/)
38. [![Preview of the Entry Interview Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/entry-interview-template-preview.avif) Entry Interview Survey Template Employee A new colleague arrives with experience you may not have discussed during recruitment. Give them room to describe useful strengths, questions, and learning preferences before filling their calendar with activities. Create the questionnaire in SurveyLegend and use it to prepare a two-way conversation.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/entry-interview-template/)
39. [![Preview of the Intern Feedback Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/intern-feedback-template-preview.avif) Intern Feedback Survey Template Employee Interns need more than a desk and a list of tasks. A short check-in can reveal whether they know what they are learning, can reach a supervisor and have a useful next step when work is unclear.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/intern-feedback-template/)
40. [![Preview of the Intern Program Feedback Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/intern-program-feedback-template-preview.avif) Intern Program Feedback Survey Template Employee Interns need space to describe learning, work, supervision and feedback. Ask during or soon after one named placement, then separate program improvement from performance evaluation. This questionnaire is not an assessment of professional competence.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/intern-program-feedback-template/)
41. [![Preview of the Job Search Priority Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/job-search-priority-template-preview.avif) Job Search Priority Survey Template Employee Two job seekers may want the same job title for very different reasons. This SurveyLegend questionnaire gives a career adviser a starting point for a conversation about the conditions that matter to each person.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/job-search-priority-template/)
42. [![Preview of the New Hire Orientation Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/new-hire-orientation-template-preview.avif) New Hire Orientation Survey Template Employee Orientation is a starting point, not the whole onboarding experience. This SurveyLegend questionnaire asks what the session helped explain while new employees can still recall its content and delivery.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/new-hire-orientation-template/)
43. [![Preview of the Organizational Culture Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/organizational-culture-template-preview.avif) Organizational Culture Survey Template Employee Values printed on a wall cannot show how decisions are made or how people respond to mistakes. This SurveyLegend questionnaire asks for recent experience and practical examples that can guide a focused culture discussion.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/organizational-culture-template/)
44. [![Preview of the Part-Time Job Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/part-time-job-template-preview.avif) Part-Time Job Survey Template Employee Two people working the same number of hours may want different schedules. This SurveyLegend questionnaire asks about employees’ preferences instead of assuming that every part-time worker wants either more hours or fewer commitments.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/part-time-job-template/)
45. [![Preview of the Peer Feedback Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/peer-feedback-template-preview.avif) Peer Feedback Survey Template Employee Ask colleagues to reflect on one named collaboration, not a person’s character. Questions about communication, commitments and response to ideas make feedback easier to discuss and act on. This questionnaire supports development; it is not a validated performance score or a substitute for fair employment processes.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/peer-feedback-template/)
46. [![Preview of the Professional Development Follow-Up Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/professional-development-feedback-template-preview.avif) Professional Development Follow-Up Survey Template Employee Send these seven questions after participants have had a realistic chance to try the learning at work. The questionnaire focuses on application opportunities, environmental support and the next useful action during a defined four-week period.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/professional-development-feedback-template/)
47. [![Preview of the Professional Development Needs Assessment Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/professional-development-needs-assessment-template-preview.avif) Professional Development Needs Assessment Template Employee A professional development needs assessment gathers evidence before learning activities are selected. It separates a development need from a process, tool, staffing or policy problem that training alone may not solve.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/professional-development-needs-assessment-template/)
48. [![Preview of the Professional Development Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/professional-development-template-preview.avif) Professional Development Survey Template Employee State the planning period and who will review the answers. Ask employees to choose one priority rather than rank an unlimited wish list. Explain which types of support are realistically in scope and that a response is not a promise of funding, promotion, certification or a particular program.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/professional-development-template/)
49. [![Preview of the Recruitment Evaluation Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/recruitment-evaluation-template-preview.avif) Recruitment Evaluation Survey Template Employee Invite the hiring team after a specific role is filled or the search ends. Name the role family and recruitment period, but do not put candidates' names or personal information into this questionnaire. Ask each participant to answer based on the stages they observed. This is a process retrospective, not a candidate scorecard or a substitute for an applicant's perspective.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/recruitment-evaluation-template/)
50. [![Preview of the Remote Workforce Engagement Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/remote-workforce-engagement-template-preview.avif) Remote Workforce Engagement Survey Template Employee Remote work changes how employees get answers, meet colleagues and protect focus time. SurveyLegend helps a people team adapt a seven-question check-in to the actual rhythm of its distributed team.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/remote-workforce-engagement-template/)
51. [![Preview of the Return-to-Work Support Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/return-to-work-template-preview.avif) Return-to-Work Support Survey Template Employee Use this survey after an employee has returned and had time to experience the agreed plan. It asks about work arrangements and support, not diagnosis, treatment or fitness for work. Keep individual accommodation requests in the organization’s confidential case process.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/return-to-work-template/)
52. [![Preview of the Workplace Safety Culture Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/safety-culture-template-preview.avif) Workplace Safety Culture Survey Template Employee Use this survey to learn how employees experience everyday safety priorities during the past three months. It asks about supervisors, coworkers, reporting and training. Keep urgent hazard reporting and formal incident investigation in the organization’s established safety channels.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/safety-culture-template/)
53. [![Preview of the Employee Pay Satisfaction Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/salary-template-preview.avif) Employee Pay Satisfaction Survey Template Employee “Salary satisfaction” can hide several different issues. An employee may accept the pay level but find raise criteria unclear, or trust the criteria while experiencing payroll errors. This original template separates those experiences so HR can identify a process to investigate. Browse \[employee templates\](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/) when the task concerns another stage of work.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/salary-template/)
54. [![Preview of the Sales Enablement Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/sales-enablement-template-preview.avif) Sales Enablement Survey Template Employee A sales team may have a large library of materials but still struggle to find the right answer when a prospect asks. SurveyLegend helps leaders gather task-level feedback before changing content or training.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/sales-enablement-template/)
55. [![Preview of the Sales Team Coordination Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/sales-team-template-preview.avif) Sales Team Coordination Survey Template Employee Use the survey after a defined month of team selling, especially when several people contribute to the same account. A useful sales resource does little good if the next owner cannot find it or does not know an action is theirs. Adapt this SurveyLegend example to the coordination process rather than using it to grade individual sellers.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/sales-team-template/)
56. [![Preview of the Employee Skills Self-Assessment Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/skills-assessment-form-template-preview.avif) Employee Skills Self-Assessment Template Employee A skills self-assessment gathers a person's experience and support needs for development. It is not a validated test, certification or hiring screen. Explore employee templates and employee recognition for related tasks.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/skills-assessment-form-template/)
57. [![Preview of the Staff Availability Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/staff-availability-template-preview.avif) Staff Availability Survey Template Employee A preference is not the same as a time someone can actually work. Collect the period, available windows and scheduling preferences clearly so managers do not have to guess what a short reply means.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/staff-availability-template/)
58. [![Preview of the Staff of the Month Voting Form Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/staff-of-the-month-voting-form-template-preview.avif) Staff of the Month Voting Form Template Employee This form captures a nomination and concrete example. A committee should verify eligibility and fairness; raw popularity does not establish performance. Related SurveyLegend material: employee recognition and employee templates.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/staff-of-the-month-voting-form-template/)
59. [![Preview of the Team Building Survey Template showing its first question and answer choices](https://www.surveylegend.com/survey-template-media/previews/team-building-template-preview.avif) Team Building Survey Template Employee An enjoyable activity and a useful team conversation are not necessarily the same thing. This SurveyLegend questionnaire helps you evaluate the session against its purpose while making room for different participant experiences.](https://www.surveylegend.com/survey-examples-templates/human-resource-and-employee-satisfaction-surveys/team-building-template/)

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