"Ada Reasonable Accommodation Request Form" - Delaware

Ada Reasonable Accommodation Request Form is a legal document that was released by the Delaware Department of Human Resources - a government authority operating within Delaware.

Form Details:

  • The latest edition currently provided by the Delaware Department of Human Resources;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Department of Human Resources.

ADVERTISEMENT
ADVERTISEMENT

Download "Ada Reasonable Accommodation Request Form" - Delaware

420 times
Rate (4.8 / 5) 29 votes
Reasonable Accommodation Request Form
ACCOMMODATION REQUEST QUESTIONNAIRE
The purpose of the questionnaire is to make a determination about whether an employee qualifies for an
accommodation consistent with the Americans with Disabilities Act (ADA) and, if so, to identify reasonable
accommodations. Please respond completely and attach appropriate backup documentation (e.g. medical
certification). This form should be completed by Human Resources, in consultation with the supervisor
(when appropriate) and the employee for whom the accommodation is sought.
Employee Name:
Position:
Division:
Unit/Facility:
1. What limitation is interfering with the employee’s ability to perform the job or access a benefit or privilege
of employment?
2. What is the specific job function or work activity being impacted or limited by the disabling condition AND
to what extent (e.g. keyboard placement)?
3. What is the specific accommodation(s) being requested?
a. How does the accommodation enable the employee to perform the essential functions of the
job?
b. If applicable, provide additional accommodations that may be appropriate.
4. Please include additional, relevant information.
Name of person completing form:
Title:
Signature:
Date:
Relationship to Employee (e.g. Supervisor, Manager, Administrator)
Reasonable Accommodation Request Form
ACCOMMODATION REQUEST QUESTIONNAIRE
The purpose of the questionnaire is to make a determination about whether an employee qualifies for an
accommodation consistent with the Americans with Disabilities Act (ADA) and, if so, to identify reasonable
accommodations. Please respond completely and attach appropriate backup documentation (e.g. medical
certification). This form should be completed by Human Resources, in consultation with the supervisor
(when appropriate) and the employee for whom the accommodation is sought.
Employee Name:
Position:
Division:
Unit/Facility:
1. What limitation is interfering with the employee’s ability to perform the job or access a benefit or privilege
of employment?
2. What is the specific job function or work activity being impacted or limited by the disabling condition AND
to what extent (e.g. keyboard placement)?
3. What is the specific accommodation(s) being requested?
a. How does the accommodation enable the employee to perform the essential functions of the
job?
b. If applicable, provide additional accommodations that may be appropriate.
4. Please include additional, relevant information.
Name of person completing form:
Title:
Signature:
Date:
Relationship to Employee (e.g. Supervisor, Manager, Administrator)