To employer:

 

Date

Name of Institution

Address of Institution

Re: Reasonable Accommodation Request

 

Dear “Mr./Ms./Dr” or “To whom it may concern”:

I work at ________ (Company name) as a ________ (Your job title) and have been in this position since _________ (Spell out date).

I am writing to request possible future accommodation (Or write the current accommodation request) for my chronic disability under the Americans with Disabilities Act (ADA) of 1990 that prohibits discrimination against individuals with disabilities and requires, under Title I of the Americans with Disabilities Act, a reasonable accommodation (a modification or adjustment) of a job or the work environment to allow me to:

1) perform the essential functions of a job; and

2) enjoy equal benefits and privileges of employment.

As seen by the attached physician’s letter, I have chronic migraines (replace with episodic, if that is your diagnosis). This is a debilitating neurological disorder that can be worsened or offset by “triggers” in the environment.

(If you need accommodations now, include:)

I am writing to request that you provide __________________ (list accommodation needed here). This (“these” if more than one) accommodation(s) will allow me to perform the essential functions of my job.

If you are unable to provide me with _______ (list accommodation needed here), I ask that we engage in the mediation process to determine whether there is an alternative effective accommodation.

Please contact me if you have any questions about my request. I would appreciate a written response to this letter as soon as reasonably possible.

Thank you very much.

Regards,

_____________________ 

_____________________

(Your name and contact details)

 

 

For your physican to sign:

 

Date

Name of Institution

Address of Institution

Re: Medical Verification of Disability

 

Dear “Mr./Ms./Dr” or “To whom it may concern”:

I am writing this letter on behalf of ________ (Your name). (She/he/they) is (are if “they” is used) currently my patient and is diagnosed with________(episodic or chronic) migraines. This is a disabling condition for her/him/them and falls under the protections that the Americans with Disabilities Act (ADA) of 1990 provides.

 

___________ (Your name) may require accommodations as this condition can be exacerbated or triggered by noise, lights, temperature, scents, etc. Moreover, this complex neurological, debilitating condition may- in addition to a headache- impact vision, the musculoskeletal system causing weakness, result in nausea or vomiting, cause fatigue, and/or an inability to concentrate among many other symptoms.

 

I am working with ________ (Your name) on different treatments so that (he/she/they) can function as unimpeded as possible, but if accommodations are necessary, it will be a reasonable ask considering the circumstances of (her/his/their) condition.

 

Feel free to contact me if you have any further questions regarding the status of their disability.

 

Sincerely,

 

Dr. _______________

____________________