Accommodation Request Form

Accommodation Request Form — Form Fields

This hr template includes 9 fields. Request workplace accommodations for disabilities or medical conditions. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Job Title (text, required)
• Department (text, required)
• Email Address (email, required)
• Type of Accommodation Needed (dropdown selection, required) — options: Physical/Mobility, Visual/Hearing, Schedule Adjustment, Remote Work, Equipment/Technology, Other
• Describe the Accommodation Requested (long text, required)
• How will this accommodation help you perform your job duties? (long text, required)
• Do you have supporting medical documentation? (multiple choice, required) — options: Yes, No, Will provide later
• Upload Supporting Documentation (optional) (file upload, optional)