Workplace Disability Accommodation Assessment
Employee Information
Employee Name
Employee ID
Department
Job Title
Supervisor Name
Assessment Date
Accommodation Request Details
Description of Disability/Condition
How does this condition impact job performance or workplace participation?
Accommodation(s) Requested
Supporting Documentation Provided
Yes
No
Pending
Assessment and Recommendation
Assessment Summary
Recommendation
Assessor Name
Assessor Title
Assessment Completion Date