Document text
Reasonable Accommodation Request for a Job Application, Test or Interview
[YOUR FULL NAME]
[STREET ADDRESS]
[CITY, STATE ZIP]
Phone: [PHONE NUMBER] · Email: [EMAIL]
[EMPLOYER'S NAME]
Attn: [RECRUITER / HR CONTACT NAME]
[EMPLOYER'S ADDRESS OR EMAIL]
[DATE]
Re: Request for reasonable accommodation in the hiring process — [JOB TITLE], requisition [JOB ID OR REFERENCE]
Dear [RECRUITER'S NAME],
I am applying for the [JOB TITLE] position (reference [JOB ID OR REFERENCE]). Because of a medical condition, I need an adjustment to part of your application process so that I can be considered on an equal basis with other applicants. I am asking for a reasonable accommodation under the Americans with Disabilities Act (42 U.S.C. 12112(b)(5); 29 CFR 1630.2(o)(1)(i) and 1630.9).
1. Which step of the hiring process
[THE ONLINE APPLICATION FORM / THE TIMED ASSESSMENT ON (DATE) / THE INTERVIEW ON (DATE) AT (LOCATION) / THE SKILLS DEMONSTRATION]
2. What I am asking for
[FOR EXAMPLE: AN ALTERNATIVE WAY TO SUBMIT THE APPLICATION, SUCH AS BY EMAIL OR WITH A READER / EXTRA TIME OF (AMOUNT) ON THE WRITTEN TEST / THE TEST IN LARGE PRINT OR SCREEN-READER-COMPATIBLE FORMAT / A SIGN LANGUAGE INTERPRETER / AN INTERVIEW ROOM ON THE GROUND FLOOR / A VIDEO INTERVIEW INSTEAD OF IN PERSON]
3. Why it is needed
[ONE OR TWO SENTENCES ON THE FUNCTIONAL LIMITATION, E.G. "I HAVE A CONDITION THAT LIMITS MY ABILITY TO READ STANDARD PRINT." YOU DO NOT NEED TO GIVE A DIAGNOSIS IN THIS LETTER.]
If you would like to discuss other options that would work equally well, I am happy to do so. If my need for this accommodation is not obvious and you require documentation, please tell me what information you need and I will provide reasonable documentation from [MY HEALTH CARE PROVIDER].
4. Confidentiality
Please keep this letter and any medical information I provide separate from my application materials and share it only with those who need it to arrange the accommodation.
5. Timing
Because the [TEST / INTERVIEW] is scheduled for [DATE], I would be grateful for your reply by [DATE, A FEW DAYS BEFORE], so that the arrangements can be made in time. Please do not treat this request as a reason to withdraw or delay my application.
Thank you for your help.
Sincerely,
____________________
[YOUR FULL NAME]
For me
[ ] Request sent on [DATE] to [NAME / EMAIL], copy kept
[ ] Employer's reply received on [DATE]: [ACCEPTED / ALTERNATIVE OFFERED / REFUSED]
[ ] If refused or ignored: EEOC charge generally within 180 days (300 days in some states) of [DATE]