How to Use This Template

Use this template to record accommodation requests from employees. Having a clear support policy and request procedure promotes an inclusive workplace and avoids employer vulnerability. Normalizing support requests helps employees feel comfortable and confident in seeking the support they need to succeed at work. 

Developing a simple accommodation request template form is a low-barrier way to be more inclusive in your workplace. Include guidelines for how to use your form at the same time. Use this accommodation policy template in this toolkit to get started with the guidelines.

Consider not requiring a medical note or assessment as a requirement for support requests. Doing this reduces barriers to equitable employment.

Tip: While most support requests are low-cost, NDMS may be able to help offset any costs associated with providing support. Contact us today to learn more about support and funding. Normalizing support requests as a standard workplace practice ensures all employees can contribute fully and equitably.

Instructions

1. Update the sections in bolded text to include your company’s information.  
2. Then, delete all remaining blue instruction text when you are finished.

Template

Name of employee: [to be completed by person filling out the form]

Name of person completing this form (if not the employee): [to be completed by person filling out the form]

Requested support: 

• [Support request 1]
• [Support request 2]

Name of supervisor: [to be completed by person filling out the form]

Date of request: [to be completed by person filling out the form]