ADA Accommodation Denial and Employment Termination Notice
Complete this form to document the denial of an ADA accommodation request and notify the employee of employment termination.
Employee Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Employee Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Job Title
*
Department
*
Date of Accommodation Request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Accommodation Requested
*
Reason for Accommodation Denial
*
Termination Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Employment Termination
*
Manager or HR Representative Name
*
First Name
Last Name
Manager or HR Representative Email
*
example@example.com
Additional Comments (if any)
Employee Acknowledgment of Receipt
*
Submit Notice
Submit Notice
Should be Empty: