ADA Accommodation Request Analysis Form
Documentation of the Interactive Process
Final Decision:
PENDING
REASONABLE ACCOMMODATION REQUEST LOG
Employee: Employee Name | Job Title: Job Title
Analysis Date: --- | Request Date: ---
1. Disability and Limitation
Self-Identified Disability:
Detailed description of how the disability limits essential job functions.
2. Essential Job Function Analysis
| # | Function Description | Essential? | Impaired by Disability? |
|---|
3. Proposed Accommodation & Hardship Review
Accommodation Requested:
Alternative solutions reviewed during the Interactive Process.
Undue Hardship Rationale:
Analysis of whether the requested accommodation creates significant difficulty or expense.
4. Final Determination
Outcome:
Justification:
HR / Compliance Officer
Department Manager
Employee & Request Information
Essential Job Functions (EJF)
List the core, non-negotiable duties of the position.