SAMPLE REQUEST FOR ACCOMMODATION

Modified or Part-Time Schedule

MEMORANDUM

TO: (1) ______

FROM: (2) ______

RE: Request for Reasonable Accommodation

DATE: (3) ______

This is a request for reasonable accommodation under the Americans with Disabilities Act (ADA) and the California Fair Employment and Housing Act (FEHA). If you are not the appropriate person to receive this request, please notify me immediately, and forward this letter on to the person who handles requests for reasonable accommodation.

I am a person with a “disability” under state and federal laws. [My condition is (4) ______.] Due to my disability, (5) ______.

According to the ADA and the federal Equal Employment Opportunity Commission (EEOC), a modified or part-time schedule can be a form of reasonable accommodation. See 42 U.S.C. § 12111(9)(B) and the sections entitled “Leave” and “Modified or Part-Time Schedule” in EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, both available at www.eeoc.gov.

Please let me know if you require reasonable medical documentation of my condition, or if you wish to propose alternative accommodations to those I have requested. I am ready and willing to engage in the interactive process with you so that I may continue in my employment.

Thank you.

(1) Name of Human Resources director, supervisor, program director, or another manager

(2) Your name

(3) Today’s date

(4) Optional: State the name or a description of your condition using language you feel comfortable with.

(5) Explain the modified schedule you are seeking and how it relates to your disability. Examples:

“My treatments for cancer are causing fatigue. I would like to work a part-time schedule of 20 hours per week for the next six months.”

“My medication is causing me to be groggy and nauseous in the morning. I would like to change my start time from 8:30 a.m. to 9:30 a.m., and then work until 6:00 p.m.”

“Because of my seizure disorder, my doctor has advised me to avoid night and swing shifts. I would like to work a regular daytime schedule.”

“I have a therapy appointment every Wednesday at 1:00 p.m. I would like to take a long lunch on Wednesdays and make up the time later.”