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It collects employee details, the specific accommodations requested, and disability-related limitations without requiring disclosure of diagnosis. It provides a physician/health care provider certification section when disability needs are not apparent, an employer section for interactive process documentation and accommodation recommendations, and employer sections to list granted or denied accommodations, supporting rationales, and implementation follow-up.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/request-for-reasonable-accommodation-confidential-reasonable-accommodation-package/280364/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/request-for-reasonable-accommodation-confidential-reasonable-accommodation-package/280364.png","ImageObject",442,249,{"name":88,"@type":89},"Ivy","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information must the employee provide in the reasonable accommodation request?","Question",{"text":109,"@type":110},"The employee must provide their identity and work contact details, the specific accommodation(s) requested, and the reason for the request describing disability-related limitations and how the accommodation will help perform essential job functions.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Can the employee be asked to disclose a diagnosis?",{"text":114,"@type":110},"The form states the employer does not require diagnosis disclosure. The request should explain disability-related limitations, while medical certification instructions also indicate verification of disability without providing the diagnosis.",{"name":116,"@type":107,"acceptedAnswer":117},"When is physician or health care provider certification required and what must it include?",{"text":118,"@type":110},"If the disability or need for accommodation is not apparent or known to the employer, the employer may request certification. The provider must verify disability (without diagnosis), describe how limitations impair job duties and whether they are temporary or permanent, and recommend specific reasonable accommodations.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},280364,1789538068,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":73},549758252649,"https://ap-avatar.wpscdn.com/avatar/8000253669c5317157?_k=1778319167496531819","Request For Reasonable Accommodation-Confidential  \nThe California Fair Employment and Housing Act requires employers of five or more employees to provide reasonable accommodation for individuals with a physical or mental disability to perform the essential functions of their job unless it would cause an undue hardship. The law does not require the use of this or any other form to make a request for a reasonable accommodation. This form and any supporting materials or information is confidential and should be kept separate from an employee’s personnel file.  \n\n| SECTION A: TO BE COMPLETED BY EMPLOYEE |  |  |\n| --- | --- | --- |\n| NAME OF EMPLOYEE | CLASSIFICATION/JOB TITLE |  |\n| WORK LOCATION/SUPERVISOR | WORK TELEPHONE NUMBER/EMAIL |  |\n| ACCOMMODATION(S) REQUESTED ( Be as specific as possible, for example adaptive equipment, reader, interpreter, training, schedule change, etc.): |  |  |\n| REASON FOR REQUEST (Please do not disclose your diagnosis; explain your disability-related limitations and how this accommodation will help you do your job. ) |  |  |\n| IS YOUR LIMITATION:\u003Cbr>Permanent Temporary Unknown |  | ANTICIPATED RECOVERY DATE (if any) |\n| IS THE ABOVE DESCRIBED DISABILITY THE SUBJECT OF A WORKER’S COMPENSATION CLAIM? (Employees with work related injuries may also be eligible for a reasonable accommodation independent of the worker’s compensation process. )\u003Cbr>YES NO IF YES, DATE FILED: |  |  |\n| HAVE YOU REQUESTED FMLA, CFRA, PDL, OR OTHER LEAVE IN CONNECTION WITH THE ABOVE DESCRIBED DISABILITY? YES NO IF YES, PLEASE SPECIFY WHAT YOU REQUESTED AND WHEN: |  |  |\n| I CERTIFY THAT I HAVE A DISABILITY THAT REQUIRES REASONABLE ACCOMMODATION, WHICH WILL BE MET BY THE ACCOMMODATION(S) LISTED ABOVE. |  |  |\n| SIGNATURE OF EMPLOYEE DATE |  |  |\n\nREASONABLE ACCOMMODATION PACKAGE / 8.2016 1  \n\n| SECTION B: CERTIFICATION FROM PHYSICIAN/HEALTH CARE PROVIDER\u003Cbr>When an employee’s disability or need for accommodation is not apparent or known to the employer, the employer may request a certification from a health care provider verifying that an accommodation is necessary. The employer should provide the employee with a copy of a job duty statement to share with the health care provider. |  |\n| --- | --- |\n| For completion by the health care provider: please provide a letter or verification addressing the following:\u003Cbr>1. Verification that the employee has a disability (but not the diagnosis) .\u003Cbr>2. Description of how the employee’s limitations impair the ability to perform the duties of the job and indication of whether these limitations are temporary or permanent.\u003Cbr>a. If temporary, state when they are expected to end.\u003Cbr>3. Recommendation of specific reasonable accommodation(s) .\u003Cbr>(Note: Use the space below or attach a letter or verification, which will be kept confidential. Employers must generally retain medical certifications and related documents separately from usual personnel files.) |  |\n| DATE ACCOMMODATION TO BEGIN | DATE ACCOMMODATION TO END OR CONTINUOUS |\n| NAME OF HEALTH CARE PROVIDER | SIGNATURE OF HEALTH CARE PROVIDER |\n\nREASONABLE ACCOMMODATION PACKAGE / 8.2016 2  \n\n| SECTION C: INTERACTIVE PROCESS DISCUSSION TO BE COMPLETED BY EMPLOYER |\n| --- |\n| 1. Document all interactive discussions with employee, including dates of the discussions, employee’s specific request(s), names of all persons present, and what was discussed. Use additional pages if required.\u003Cbr>Date Discussion Notes |\n| 2. List all potential reasonable accommodations identified in the interactive discussions and the strengths and weaknesses for each as a potential reasonable accommodation. |\n| 3. State your recommended reasonable accommodation and the rationale for your recommendation. |\n\nREASONABLE ACCOMMODATION PACKAGE / 8.2016 3  \n\n| SECTION D: TO BE COMPLETED BY EMPLOYER |  |\n| --- | --- |\n| LIST SPECIFIC ACCOMMODATION(S) TO BE PROVIDED: |  |\n| For each accommodation requested by the employee that you deny, explain the reason for the denial:","cbCaikuuNokoJLLU","https://ap.wps.com/l/cbCaikuuNokoJLLU","pdf",2223158,"English","# SECTION A: TO BE COMPLETED BY EMPLOYEE\n## NAME OF EMPLOYEE / CLASSIFICATION/JOB TITLE\n## WORK LOCATION/SUPERVISOR / WORK TELEPHONE NUMBER/EMAIL\n## ACCOMMODATION(S) REQUESTED / REASON FOR REQUEST\n## LIMITATION STATUS AND ANTICIPATED RECOVERY DATE\n## WORKER’S COMPENSATION AND LEAVE REQUESTS\n## EMPLOYEE CERTIFICATION / SIGNATURE AND DATE\n# SECTION B: CERTIFICATION FROM PHYSICIAN/HEALTH CARE PROVIDER\n## CERTIFICATION REQUIREMENTS AND PROVIDER DETAILS\n# SECTION C: INTERACTIVE PROCESS DISCUSSION TO BE COMPLETED BY EMPLOYER\n## DOCUMENTATION AND ACCOMMODATION EVALUATION\n# SECTION D: TO BE COMPLETED BY EMPLOYER\n## LIST OF ACCOMMODATION(S) AND DENIAL RATIONALES\n## RECEIPT ACKNOWLEDGEMENT AND ACCOMMODATION DATES\n# SECTION E: TO BE COMPLETED BY EMPLOYER FOLLOWING IMPLEMENTATION\n## CHECK-IN REQUIREMENTS AND REENGAGEMENT","[{\"question\":\"What information must the employee provide in the reasonable accommodation request?\",\"answer\":\"The employee must provide their identity and work contact details, the specific accommodation(s) requested, and the reason for the request describing disability-related limitations and how the accommodation will help perform essential job functions.\"},{\"question\":\"Can the employee be asked to disclose a diagnosis?\",\"answer\":\"The form states the employer does not require diagnosis disclosure. The request should explain disability-related limitations, while medical certification instructions also indicate verification of disability without providing the diagnosis.\"},{\"question\":\"When is physician or health care provider certification required and what must it include?\",\"answer\":\"If the disability or need for accommodation is not apparent or known to the employer, the employer may request certification. The provider must verify disability (without diagnosis), describe how limitations impair job duties and whether they are temporary or permanent, and recommend specific reasonable accommodations.\"}]","Request For Reasonable Accommodation - Confidential - Reasonable Accommodation Package | PDF"]