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ADA Accommodation Medical Request Form

Product Specifications:

  • This form is 8.5" x 11" 
  • 50 sheets/pkg


* Required Fields


According to the ADA, employers should make reasonable accommodations for employees with disabilities. These accommodations should help employees to perform the functions of their jobs more easily and comfortably. For example, if an employee is bound to a wheelchair, the employee may request that the employee provide a lower work station with enough space to accommodate the wheelchair.

Employees are responsible for making Accommodation Requests if they have special needs that are covered by the ADA. In order to make a request, employees should submit a formal request letter to the employer along with an Accommodation Medical Release Form, which allows employers to obtain medical information about the employee from a treating medical practitioner.

The Medical Request Form should be completed by a physician or other medical practitioner who has treated or seen the employee with the disability. The medical practitioner should provide information about how the disability impacts the employee’s lifestyle and ability to perform the essential functions of the job (if applicable). The medical practitioner should also provide information about how an accommodation should allow the employee to complete his or her job requirements more easily or comfortably.

Who is Covered by the ADA

The ADA applies to:

  • Private sector employers with at least 15 employees
  • Employment agencies
  • Labor organizations
  • Joint labor/management committees
  • State, local, and federal government entities

All employees and job applicants are covered if they work for, have worked for, or are applying to work for a covered employer. In order for individuals to be covered, they need to have a qualifying disability, which often includes a recognized physical disability.

Properly accommodate and document a leave by obtaining the correct form initially with the Accommodation Medical Request Form.

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