MEMORANDUM
TO: (1) ____________________________
FROM: (2) ____________________________
RE: Request for Reasonable Accommodation
DATE: (3) ________________________
This is a request for reasonable accommodation under the Americans with Disabilities Act (ADA) and the California Fair Employment and Housing Act (FEHA). If you are not the appropriate person to receive this request, please notify me immediately, and forward this letter on to the person who handles requests for reasonable accommodation.
I am a person with a “disability” under state and federal laws. [My condition is (4) _________________.] I am requesting a leave of absence. (5) __________________________________________. My scheduled return to work date is (6) _______.
According to the federal Equal Employment Opportunity Commission (EEOC), a leave of absence is a form of reasonable accommodation. See the section entitled “Leave” and corresponding examples in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, available at www.eeoc.gov.
Please let me know if you require reasonable medical documentation of my condition, or if you wish to propose alternative accommodations to those I have requested. I am ready and willing to engage in the interactive process with you so that I may continue in my employment. (7)
Thank you.
(1) Name of Human Resources director, supervisor, program director, or another manager
(2) Your name
(3) Today’s date
(4) Optional: State the name or a description of your condition using language you feel comfortable with.
(5) Explain why you are requesting leave, for example: “I need surgery and time to recuperate.”
(6) Be sure to include a return to work date, even if you need to change the date later. Let your employer know promptly if your return to work date changes. Provide a doctor’s note or other medical documentation with the revised return-to-work date before the original date goes by.
(7) It is very important to communicate with your employer during your leave, particularly toward the end of your leave.
As you are preparing to return to work, contact your employer to confirm your plans and to request instructions.
If your employer has a maximum leave policy, and you need an extension of leave beyond the maximum amount, make a specific request in writing for a further extension.