SAMPLE REQUEST FOR ACCOMMODATION

Leave of Absence
(1) Name of Human
Resources director,
MEMORANDUM supervisor, program
director, or another manager
TO: (1) ____________________________ (2) Your name
FROM: (2) ____________________________ (3) Today’s date
RE: Request for Reasonable Accommodation
DATE: (3) ________________________

(4) Optional: State the

This is a request for reasonable accommodation under the name or a description of
your condition using
Americans with Disabilities Act (ADA) and the California Fair language you feel
Employment and Housing Act (FEHA). If you are not the comfortable with.
appropriate person to receive this request, please notify me
(5) Explain why you are
immediately, and forward this letter on to the person who handles requesting leave, for
requests for reasonable accommodation. example: “I need surgery
and time to recuperate.”
I am a person with a “disability” under state and federal laws. [My (6) Be sure to include a
condition is (4) _________________.] I am requesting a leave of return to work date, even
absence. (5) __________________________________________. if you need to change the
My scheduled return to work date is (6) _______. date later. Let your
employer know promptly if
According to the federal Equal Employment Opportunity your return to work date
changes. Provide a doctor’s
Commission (EEOC), a leave of absence is a form of reasonable note or other medical
accommodation. See the section entitled “Leave” and documentation with the
corresponding examples in EEOC Enforcement Guidance on revised return-to-work date
Reasonable Accommodation and Undue Hardship Under the before the original date
Americans with Disabilities Act, available at www.eeoc.gov. goes by.
(7) It is very important to
Please let me know if you require reasonable medical communicate with your
documentation of my condition, or if you wish to propose employer during your leave,
particularly toward the end
alternative accommodations to those I have requested. I am ready
of your leave.
and willing to engage in the interactive process with you so that I
may continue in my employment. (7) As you are preparing to
return to work, contact your
employer to confirm your
Thank you. plans and to request
instructions.
If your employer has a
maximum leave policy, and
you need an extension of
leave beyond the maximum
amount, make a specific
request in writing for a
further extension.