Reasonable Accommodations Agreement

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A Reasonable Accommodations Agreement can help you return to work successfully after your stroke. If your human resources department doesn’t have a similar agreement, complete the following worksheet with your employer.

Sample language for Reasonable Accommodations Agreement

The purpose of this agreement is to:

  • Make sure that the employee and supervisor have an accurate record of agreements for reasonable accommodations at work.
  • Minimize the need to re-negotiate reasonable accommodations every time the employee changes jobs, is re-located or assigned a new manager within the organization.
  •  Provide the employee and supervisor with the basis for discussions about reasonable accommodations at future meetings. This is a living document and should be reviewed regularly by the employee and supervisor and amended as appropriate.

The agreement allows employees to:

  • Explain the impact of their disability on them at work.
  •  Suggest accommodations that will make it easier to do their job; offer further information from health care professionals; and request an assessment by occupational health experts or others.
  • Review the effectiveness of current accommodations and explain any change in their circumstances.
  •  Be reassured that their supervisor knows what to do and who to contact if they become unwell at work.
  • Know how and when the supervisor will keep in touch if they’re absent from work because of illness or a disability.

The agreement allows the supervisor to:

  • Understand how an employee’s disability affects them at work.
  •  Explain the needs of the business or organization.
  • Explain the organization’s attendance and reasonable accommodations policies.

Recognize signs that an employee might be unwell and know the employee’s wishes including who to contact for help.

  •  Know how and when to stay in touch if the employee is out sick.
  • Consider if the employee needs to be referred for an assessment by an occupational health professional or another advisor to help both parties understand what accommodations are needed.
  • Review the effectiveness of the accommodations agreed upon and explain any change in the employer’s circumstances.

Reasonable Accommodations Agreement

This is a record of the Reasonable Accommodations Agreement between (Employee’s Name) and (Supervisor’s Name) of (Name of Company/Organization).

Date This agreement may be viewed and amended as necessary with the agreement of both parties:

  •  At any regular one-on-one meeting
  • At a return-to-work meeting following a period of sickness/absence
  •  At a six-month and/or annual evaluation
  •  Before a change of job, duties, introduction to new technology, or ways of working
  •  Before or after any change in circumstances for either party

Employee: My disability in the workplace

My disability has the following impact on me at work:

Date: I need the following reasonable accommodations:

Date implemented:

Wellness at work

Emergency contacts

If I’m not well enough to be at work, I give permission for my supervisor to contact 911 and/or any of the following emergency contacts in the order of preference indicated below:

Preference 1 Name: Relationship: Telephone:

Preference 2 Name: Relationship: Telephone:

Preference 3 Name: Relationship: Telephone:

I will let you know if changes to my condition affect my work and/or if the agreed accommodations are not working. We will then meet privately to discuss any further reasonable accommodations or changes that should be made. If you notice a change in my performance at work or feel the reasonable accommodations are not working, I will meet with you privately to discuss what needs to be done.

Supervisor: Keeping in touch

If you’re absent from work or on sick leave due to your disability for more than days and have followed the usual procedures for notifying the organization of your absence, I will keep in contact with you in the following way:

  • Who will contact whom?
  • How will contact be made? (email, telephone, text)
  • How often? (daily, weekly, monthly)
  • When? (preferred day and time)
  • Conversations while you are on sick leave

These are topics we have agreed we will discuss while you’re absent:

  • How you’re feeling
  •  What I can do to help
  • Current work assignments
  •  Plans for returning to work (phased in if necessary)
  •  Return to work date

Employee: Return to work

When you’re ready to return to work, we will meet to review this agreement and make any necessary adjustments.

In the meeting, we’ll also discuss:

  • Current work issues
  • A phased return/back to work plan
  • What to tell the team
  • Assessments to review existing reasonable accommodations and identify new accommodations that might be needed

Unauthorized absences from work

If you’re absent from work due to sickness or your disability and have not followed usual procedures to notify us, we have agreed that:

  •  I will try to contact you by your preferred method and/or notify your emergency contact.

An up-to-date copy of this form will be retained by employee/supervisor/HR.  A copy of this form may be given to a new or prospective supervisor with prior consent of the employee.


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