Disability Workplace Accommodation Risk Assessment

Employee Name Position/Job Title Department Assessor Assessment Date

1. Description of Employee’s Condition

Disability/Condition and Its Impact on Work

2. Essential Job Functions

List Essential Functions of the Employee’s Role

3. Accommodation Needs

Identified Need/Barrier	Proposed Accommodation	Responsibility	Comments

4. Risk Assessment

Activity/Task	Potential Risk	Likelihood	Severity	Mitigation Measures

5. Summary & Recommendations

Summary of Risks & Recommendations

Review Date/Follow-up Actions