Workplace Accommodation Request Form

Workplace Accommodation Request Form — Form Fields

This operations template includes 10 fields. Allow employees to request reasonable workplace accommodations for medical, disability, or personal health reasons. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Email Address (email, required)
• Department (text, required)
• Manager Name (text, required)
• Accommodation Type Requested (dropdown selection, required) — options: Physical Workspace Modification, Schedule Adjustment, Remote Work, Assistive Technology, Communication Support, Other
• Description of Need and Requested Accommodation (long text, required)
• Do You Have Supporting Medical Documentation? (multiple choice, required) — options: Yes – Will Provide, No, Pending from Doctor
• Is This Request Time-Sensitive? (multiple choice, required) — options: Yes – Please Expedite, No – Standard Review
• Preferred Start Date for Accommodation (text, optional)
• Additional Information (long text, optional)