ADA Accommodation Request Form: Free Download + How to Fill It Out

What's in the form

The form is structured around what the EEOC says employers can reasonably expect from an initial accommodation request. It includes:

Your identifying information. Name, position, department, date. Straightforward.

A statement that you're requesting an accommodation under the ADA. You don't need to use legal language, but explicitly referencing the ADA signals to HR that this is a formal request with legal implications — not a casual preference.

A general description of your condition. You do not need to disclose your specific diagnosis. A description like "I have a mental health condition that affects my ability to concentrate and manage stress in certain environments" is sufficient. The EEOC has confirmed that employees can start with a general description rather than a specific diagnosis. For more on what you're required to disclose, see Do You Need a Diagnosis to Get an ADA Accommodation?

Your functional limitations in a work context. This is the most important section. Describe specifically what aspects of in-office work are affected by your condition. Examples: difficulty concentrating in open-plan offices, heightened anxiety triggered by commuting or crowded environments, fatigue that makes full-day office attendance unsustainable, sensory overload from noise and interruptions. Be specific and connect limitations to the work environment.

Your requested accommodation. State clearly what you're asking for — remote work, a hybrid schedule, modified hours, a quiet workspace, or another arrangement. Be specific: "I am requesting to work remotely three days per week" is better than "I am requesting some flexibility." If you're open to alternatives, you can note that as well.

A note about supporting documentation. Indicate that you're prepared to provide clinical documentation from a qualified provider. If you already have an accommodation letter, attach it. If you don't have one yet, that's fine — submit the form first and get documentation in parallel. Your employer cannot deny your request solely because documentation wasn't included with the initial request; they're supposed to engage in the interactive process and give you reasonable time to provide it.

How to fill it out: section by section

Section 1: Employee Information Fill in your full name, job title, department, supervisor's name, and date. Use your official job title as it appears in your offer letter or HR records.

Section 2: Description of Condition Keep this brief and general. One to two sentences. You're identifying that you have a condition, not providing a medical history. Example: "I have an anxiety disorder that substantially limits my ability to concentrate and interact with others in overstimulating environments."

Don't overshare. Don't include medication names, therapy details, or personal history. HR doesn't need it at this stage, and sharing more than necessary doesn't help your case.

Section 3: Functional Limitations This is where most employees either leave too little or include the wrong kind of detail. Focus on how your condition specifically affects your ability to work in the office environment. Use concrete, workplace-specific language.

Good: "The open floor plan causes significant difficulty concentrating due to noise and visual distractions. The daily commute triggers acute anxiety symptoms that impair my ability to function for the first 1-2 hours of the workday."

Not useful: "I feel stressed at work" or "I don't like the office."

If you have documentation from a provider that describes your functional limitations, mirror that language in this section. Consistency between your request and your clinical documentation strengthens your case. For condition-specific guidance on what limitations to describe, see:

• ADA Accommodation Letter for Anxiety

• ADA Accommodation Letter for Depression

• ADA Accommodation Letter for PTSD

• ADA Accommodation Letter for ADHD

Section 4: Requested Accommodation Be specific but show flexibility. State your primary request clearly, then add a sentence indicating willingness to discuss alternatives. Example: "I am requesting a remote work arrangement for three days per week (Tuesday, Wednesday, Thursday in-office; Monday and Friday remote). I am open to discussing alternative arrangements that would address my limitations while meeting operational needs."

If a hybrid arrangement makes more sense for your situation, request that directly. If schedule modifications would help — adjusted start times, compressed weeks, built-in breaks — include those as well.

Section 5: Supporting Documentation Check the box indicating whether documentation is attached or will be provided separately. If you already have an accommodation letter from a psychologist or other qualified provider, attach it. If not, write: "Supporting clinical documentation will be provided within [X] business days."

If you need clinical documentation, WorkWell Evals provides accommodation evaluations with PSYPACT-licensed psychologists. The process takes approximately 48 hours from intake to letter delivery. See How Long Does It Take to Get an Accommodation Letter and What Does It Cost.

Common mistakes that get forms rejected

Being too vague about limitations. "I have anxiety" without any description of functional limitations gives HR nothing to work with. They need to understand specifically what the office environment does to your ability to perform.

Requesting an accommodation without connecting it to your condition. Saying "I want to work from home" without explaining why remote work specifically addresses your limitations makes it easy for HR to deny the request as a preference rather than a medical need.

Waiting for the perfect documentation before submitting. Submit the request form first. You can provide clinical documentation separately. Starting the paper trail early protects you because it timestamps when you initiated the interactive process.

Not keeping a copy. Always keep a copy of everything you submit, including the date and method of delivery. Email is ideal because it's automatically timestamped. If you hand-deliver a paper form, email a copy to HR the same day as confirmation.

Disclosing more than necessary. You don't need to share your therapy notes, medication list, or detailed personal history on the request form. That level of detail comes later, if at all, through your provider's documentation.

What happens after you submit

Your employer is legally required to engage in the interactive process. This means they must respond to your request, discuss it with you, and either approve it, propose alternatives, or explain why they're denying it with a specific reason.

In practice, many employers will send back their own forms requesting more detailed information from your healthcare provider. This is normal and expected. Having a provider who can complete these follow-up forms is critical — it's why many employees use services like WorkWell Evals' Complete Support package, which covers follow-up paperwork through the entire interactive process.

For a complete breakdown of what to expect after submission, see What Happens After Your Employer Receives Your Accommodation Letter. If your request is denied, see Your Accommodation Was Denied: Step-by-Step Action Plan.

Download the form