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A sample form for an employee to request an accommodation due to disability. A separate request form should be completed for each student needing a designated support.Blanket requests for entire classrooms will NOT be accepted. Attach additional pages as needed. The most widely requested form JAN offers is the Sample Medical Inquiry Form in Response to an Accommodation Request. With the tool, you fill out a short form that asks for information about you, the job, and the accommodation(s) you are requesting. Make your request in writing and use the phrase: "I am requesting a reasonable accommodation under the ADA. Job applicants and employees have the right to reasonable accommodations during the application process and during the employment relationship. Complete this form to request reasonable accommodations (assistive technology and services) under the Disability Program. DO NOT ATTEMPT TO TEST UNTIL YOU HAVE RECEIVED OFFICIAL CONFIRMATION FROM ICC.