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Interview accommodation request form template

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Form Title	Interview Accommodation Request Form
Form ID	[FORM_ID]
Version	1.0
Page	Page 1 of [TOTAL_PAGES]
Target Audience	Candidates, Recruiters, and Hiring Managers
Submit Completed Form To	[ACCOMMODATION_CONTACT_EMAIL]
Effective Date	[EFFECTIVE_DATE]

Completion Instructions

Candidates: Complete Sections 1, 2, and 3. Do not include specific medical diagnoses in this form; provide only information regarding your functional limitations and the specific adjustments required to participate in the interview process.
Submission: Return the completed form to [ACCOMMODATION_CONTACT_EMAIL] at least [N_BUSINESS_DAYS] business days prior to your scheduled interview.
Service Standard: [ORGANIZATION_NAME] will acknowledge receipt within [ACK_BUSINESS_DAYS] business days and initiate a confidential discussion regarding your request.
Internal Reviewers: Complete Sections 4 and 5. Evaluate the request against the core requirements of the interview and the job.
Incomplete Submissions: If this form is incomplete, a representative will contact you to gather the missing information. Your application will not be penalized for an incomplete form.

1. Requester & Subject Details

Table 1.1: Candidate and Interview Identification Fields

Field	Required?	Format/allowed values	Instruction
Candidate Full Name	Yes	Free text	Enter your legal or preferred name.
Contact Phone	Yes	[PHONE_FORMAT]	Enter your primary contact number.
Contact Email	Yes	Email address	Enter your primary email address.
Job Title Applied For	Yes	Free text	Enter the position title from the job posting.
Requisition Number	No	Alphanumeric	Enter the job posting ID, if known.
Interview Date	Yes	[DD-MMM-YYYY]	Enter the date of your scheduled interview.
Interview Time	Yes	[HH_MM_AM_PM]	Enter the start time of your interview.
Interview Format	Yes	In-person / Video / Phone	Select the scheduled format of your interview.

2. Request or Assessment Information

Table 2.1: Accommodation Requirements and Adjustments

Field	Required?	Format/allowed values	Instruction
Primary Accommodation Category	Yes	Physical access / Technology / Timing / Format / Testing / Other	Select the main area where adjustment is needed.
Description of Functional Limitation	Yes	Free text (Max 250 words)	Describe how the standard interview format limits your participation.
Requested Adjustment	Yes	Free text (Max 250 words)	Describe the specific change or tool you are requesting.
Required Accessibility Features	No	ASL / Captioning / Screen Reader / Wheelchair Access / Other	Select all features required for the interview.
Alternative Adjustment	No	Free text	Suggest an alternative option if the primary request cannot be met.
Pre-interview Contact Preference	Yes	Phone / Email / Video call	Select how you prefer to be contacted to discuss this request.

3. Supporting Documentation

Table 3.1: Documentation Intake and Verification

Field	Required?	Format/allowed values	Instruction
Documentation Attached?	Yes	Yes / No / Will provide later	Indicate if you are submitting documents with this form.
Document Type	No	Functional Capacity Form / Physician Note / Other	Select the type of document provided.
Functional Detail Provided	No	Yes / No	Does the document state limitations without a diagnosis?

Privacy and Consent Notice

The personal information collected on this form is strictly for the purpose of assessing and implementing an interview accommodation request. It will be reviewed only by [OWNER_OR_MANAGER] and individuals directly responsible for organizing the interview setup. It will not be shared with the interview panel unless necessary to implement the accommodation, and it will not factor into the hiring decision. Records are retained in a secure, separate file for [RETENTION_PERIOD] in accordance with applicable privacy legislation.

Candidate Declaration: By signing below, I confirm that the information provided is accurate and that I consent to the collection and use of this information by [ORGANIZATION_NAME] for the purpose of facilitating an interview accommodation.

Candidate Signature: _____ Date: ___

4. Review & Decision

(This section is for Internal Use Only. To be completed by [OWNER_OR_MANAGER] or designated reviewer.)

Table 4.1: Internal Assessment of Accommodation Request

Field	Required?	Format/allowed values	Instruction
Reviewer Name	Yes	Free text	Enter name of the internal evaluator.
Assessment Date	Yes	[DD-MMM-YYYY]	Enter the date the request was reviewed.
Feasibility Confirmed?	Yes	Yes / No	Can the requested adjustment be implemented practically?
BFOR Conflict Check	Yes	Yes / No / N/A	Does the request conflict with a Bona Fide Occupational Requirement?
Undue Hardship Triggered?	Yes	Yes / No	Does the request pose a health/safety risk or prohibitive cost?
Collaborative Review Required?	Yes	Yes / No	Check 'Yes' if alternative options must be negotiated with the candidate.

5. Approval & Recordkeeping

(This section is for Internal Use Only. To be completed by the final approver.)

Table 5.1: Final Decision and Implementation Tracking

Field	Required?	Format/allowed values	Instruction
Final Decision	Yes	Approved as requested / Approved with modifications / Denied	Select the final status of the accommodation request.
Decision Rationale	Yes	Free text	State the basis for the decision, particularly if modified or denied based on undue hardship.
Approved Alternative	No	Free text	Detail the exact modification to be implemented, if different from the original request.
Implementation Owner	Yes	Free text	Name the individual responsible for setting up the accommodation.
Approver Name	Yes	Free text	Enter the name of [OWNER_OR_MANAGER] authorizing the decision.
Approver Signature	Yes	Signature	Sign to finalize the internal record.
Approval Date	Yes	[DD-MMM-YYYY]	Date the decision is finalized.
Record Storage Location	Yes	Secure file path / [HRIS_NAME]	Note where this record is securely stored, separate from the candidate's application file.

What to fill in

Placeholder	What to enter	Who provides it	Required?
`[FORM_ID]`	Unique identifier for this form (e.g., HR-FRM-012).	Organization	Yes
`[TOTAL_PAGES]`	Total number of pages in the finalized document.	Administrator	Yes
`[ACCOMMODATION_CONTACT_EMAIL]`	The dedicated email address for submitting accommodation forms.	Organization	Yes
`[EFFECTIVE_DATE]`	The date this form version goes into active use.	Administrator	Yes
`[N_BUSINESS_DAYS]`	Number of days prior to the interview the form should ideally be submitted.	Organization	Yes
`[ORGANIZATION_NAME]`	Legal or operating name of the employer.	Organization	Yes
`[ACK_BUSINESS_DAYS]`	Service standard time to acknowledge receipt (e.g., 2).	Organization	Yes
`[PHONE_FORMAT]`	Expected format for telephone numbers (e.g., XXX-XXX-XXXX).	Organization	Yes
`[HH_MM_AM_PM]`	Expected time format (e.g., 09:00 AM).	Organization	Yes
`[OWNER_OR_MANAGER]`	Title of the person reviewing/approving the request.	Organization	Yes
`[RETENTION_PERIOD]`	Duration to keep the record (e.g., 1 year post-decision).	Organization	Yes
`[HRIS_NAME]`	Name of the system where records are kept, or "Confidential Drive".	Organization	Yes

Official sources

Government and professional sources this template was checked against.

This template is general information for Canadian employers, not legal advice. Employment standards, human rights and privacy rules differ by province. Check them before you use it.

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