Disability Accommodation Analysis Questionnaire

Employee/Applicant Name: ____________________________________________________ Date: _______________

Employee/Applicant Title/Position/Shift/Location: ________________________________________________________
Supervisor: ______________________________________________________________________________________
Is the employees/applicants disability obvious? If not, has it been documented (i.e. doctors note)?
Did the employee/applicant request an accommodation? Yes
No
If no, how did we become aware of the need for the accommodation?
Has the employee/applicant identified the accommodation(s) required?
accommodation(s)?

If so, what is/are the recommended

Has the employee/applicant provided medical support for the requested accommodation (i.e. doctors note)?
How long does the employee/applicant or his/her doctor believe the accommodation will be necessary? For a period of
time or indefinitely?
If the requested accommodation were provided, would the employee/applicant be limited in performing any regular duties?
If yes, how could these duties be covered? How would other employees be impacted?
What costs, if any, would be associated with allowing the accommodation? (If any, explain and quantify)
Equipment/Modifications?
Additional headcount (new hire)?
Overtime for other employees?
Interference with other employees ability to do their work?
Inability to complete contracted work or accept new work?
Other?
Has a similar accommodation been provided to this or another employee/applicant previously? If so, what was the
experience?
If client/supervisor is not in favor of providing requested accommodation, what is concern? If concern it that it will alter
current workflow/processes, how?
Is there another accommodation that could be provided that would not cause an undue hardship? If so, has it been
discussed with the employee/applicant?
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