Sample request for a change at work
A printable from Disability Accommodation at Work. Fill it in by hand. Nothing you write is collected by this website.
Sample request for a change at work
Date: ______________ To: ______________ (supervisor or HR)
I am asking for a reasonable accommodation because of a health condition.
What is hard for me at work right now: ______________ The change I am asking for: ______________ Starting on: ______________ For about how long: ______________
I can provide a note from my health care provider if needed. I am open to talking about other changes that would also work. Please let me know when we can meet, and please reply in writing.
Thank you, Name: ______________ Phone: ______________
Keep a copy. Write down who you gave it to and when.
From Disability Accommodation at Work. Facts checked October 21, 2026. Free information, not legal or medical advice.