Sample Forms

The use of these sample resource documents is not required by law. The provisions in the sample resource documents do not necessarily represent legal obligations, but instead reflect topics that employers and employees may voluntarily choose to address. The sample resource documents do not constitute legal advice by the U.S. Department of Labor and do not reflect the full range of laws that may apply in every situation, including local and state laws that may provide additional protections and requirements. Employers should review local, state, and federal laws to ensure they are in compliance with the law that provides the most protections for employees and should include additional legal requirements as necessary in their own agreements. Parties remain independently responsible for complying with applicable law.

Unlike some other federal laws, the Americans with Disabilities Act (ADA) does not require employers to use standardized forms for ADA-related employment actions. However employers sometimes find it helpful to develop forms for consistency and efficiency. The problem with using standardized forms under the ADA is that in some cases the improper use of those forms can lead to ADA violations. This can sometimes happen when employers use forms to request medical information. The ADA limits how much medical information can be gathered from employees in various situations, and employers are prohibited from asking for medical information they already have. When a standard form is used to gather disability-related information in response to a request for accommodation, sometimes the employer may be asking for more information than is necessary or appropriate under the ADA. For example, employers are not supposed to ask for proof of disability when the disability and/or need for accommodation is obvious or has already been documented.

JAN offers a number of sample forms. Employers may use these sample forms as a template for customizing forms or documents used during the interactive process, such as for documenting requesting for accommodation, requesting disability-related information, approving or denying accommodations, documenting temporary accommodations, or monitoring implemented accommodations, etc. JAN encourages employers to customize these forms, or to use them as a guide for drafting their own.

The most widely requested form JAN offers is the Sample Medical Inquiry Form in Response to an Accommodation Request. This form is commonly used to obtain information from a healthcare provider to substantiate that an employee has a medical impairment, associated limitations, and requires accommodation under the ADA. JAN encourages employers to customize each medical inquiry to obtain the information that is necessary for each individual accommodation situation. For example, some sections of the medical inquiry form might be highlighted for completion by the healthcare provider, while others may be modified to address a unique situation, or removed entirely. It can also be useful to simply draft a customized letter that includes only the questions that are necessary to move forward in the interactive process to identify an effective reasonable accommodation.

Another frequently requested form is the Sample Reasonable Accommodation Request Form for Employers . According to the Equal Employment Opportunity Commission (EEOC), the federal agency charged with enforcing the ADA, an accommodation request does not have to be in writing and the ADA does not include specific guidelines or forms for requesting reasonable accommodation. However, some employers find it useful to document accommodation requests and want to have a standard form for employees to use when requesting accommodations. For these employers, JAN developed a sample accommodation request form.

The following JAN and other sample forms are available free of charge. If you have any questions regarding the use or customization of these forms, please contact JAN.

JAN Sample Forms

• Practical Guidance for Medical Professionals: Providing Sufficient Medical Documentation in Support of a Patient's Accommodation Request
• Sample Accommodation Approval Form
• Sample Accommodation Denial Form
• Sample Appeal of a Reasonable Accommodation Determination Form
• Sample Form for Monitoring Accommodations
• Sample Limited Medical Documentation Form
• Sample Medical Inquiry Form in Response to a Request for Leave as an Accommodation
• Sample Medical Inquiry Form in Response to an Accommodation Request for the Hiring Process
• Sample Medical Inquiry in Response to an Accommodation Request Form
• Sample Onboarding Form
• Sample Plan of Action
• Sample Reasonable Accommodation Request Form for Employers
• Sample Reasonable Accommodation Request Form for the Hiring Process
• Sample Temporary/Trial Accommodation Approval Form
• How to Inform an Employer That an Accommodation is Not Effective and a Sample Letter
• Telework Accommodation Request Flowchart
• Hiring Process Reasonable Accommodation Flowchart

Other Sample Forms

• California Reasonable Accommodation Package
• Kaiser PermanenteReturn to Work Functional Assessment Form - For use by physicians to return employees back to work at full duty or provide work restrictions/capacities for employees returning via a transitional work program - and Physical Capacities Assessment Form (.doc)
• Reed Group Sample Forms
  • Accommodation Checklist
  • Accommodation Request Form
  • Accommodation Request Assessment Form

  Associated JAN Publications

  • Medical Inquiry in Response to an Accommodation Request
  • Monitoring Reasonable Accommodations
  • Providing Temporary or Trial Accommodation Solutions

  Situations and Solutions:

  The following situations and solutions are real-life examples of accommodations that were made by JAN customers. Because accommodations are made on a case-by-case basis, these examples may not be effective for every workplace but give you an idea about the types of accommodations that are possible.

  During a conversation with her supervisor, an employee disclosed that she was not meeting the performance goals of her position because she was having difficulty concentrating, staying organized, and managing her time, due to adjustments made to her medic

  he employee did not make a request for accommodation in a formal way, but the supervisor wanted to insure that he was handling the situation appropriately. He thought it was important to document the employee’s disclosure and to begin engaging in the interactive process under the ADA. The supervisor contacted JAN for guidance on how to discuss and document the employee’s possible need for accommodation. A JAN consultant explained the interactive process, that the employee’s disclosure is a request for accommodation, and shared JAN’s Sample Reasonable Accommodation Request Form for Employers to provide to the employee, in order to clarify and document her accommodation needs.

  An HR consulting firm was asked by a small business to develop a reasonable accommodation procedure that includes a process for requesting disability-related information when employees request accommodation.

  The employer requested that any forms used in the process limit the scope of information requested only to what is necessary to provide accommodation under the ADA. The HR firm contacted JAN seeking a sample form. A JAN consultant shared JAN’s Sample Medical Inquiry Form in Response to an Accommodation Request and offered practical ideas for customizing the form on an individualized basis. For example, to add questions at the end of the form to learn more about the impact of an individual’s medical impairment on performing specific job duties.

  A graphic design artist working for a non-profit requested to work at home two days a week to cope with side effects from cancer treatment.

  The employer was open to the idea, but had not permitted employees to work at home before and was uncertain if this would be an effective solution for both the employee and the business. A JAN consultant suggested implementing working at home on a trial basis and offered JAN’s Sample Temporary/Trial Accommodation Approval Form to assist the employer in documenting the accommodation. Using practical ideas shared by JAN for implementing work at home as an accommodation, the employer drafted a trial accommodation agreement and approved the accommodation for a three-month period.