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) _________________.] Due to my disability, I am requesting the following modification of workplace policy: (5) ______________________________________________.
According to the ADA and the federal Equal Employment Opportunity Commission (EEOC), modified policies are a form of reasonable accommodation. See 42 U.S.C. § 12111(9)(B) and the section entitled “Modified Workplace Policies” in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, both 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.
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) Describe the modification to the workplace policy or rule you are seeking and how it relates to your disability. Examples:
“Due to my cancer treatments, I need to constantly drink water. I would like to carry water on the floor.”
“I would like to use a stool while working the checkout station because of my knee and ankle injury.”
“Because of my disability, I have difficulty concentrating and can get startled by noises around me. I would like to listen to music on headphones at work.”
“Because of my diabetes, I sometimes need to eat immediately. I would like to keep food at my desk.”
“Because of my disability, I need unscheduled bathroom breaks – I cannot wait for my scheduled break.”
“I need an extension of leave beyond what is provided in our employee handbook.”
“I need a transfer even though I haven’t been in my current assignment the minimum year.”