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What are ADA and PWFA Leave Accommodation Request Forms?

Getting to know your options for an ADA or PWFA accommodation

Quick answer
 These forms apply when you need leave for your own medical condition (ADA) or for pregnancy, childbirth, or a related medical condition (PWFA), and can't use FMLA, a job-protected state leave, or a company leave. Submitting the form starts an interactive dialogue with your employer about whether your leave can be protected as an accommodation.

Who this applies to / Prerequisites

  • Employees who need leave for their own medical condition, or for pregnancy/childbirth/related conditions, and are not eligible for FMLA, a job-protected state leave, or a company leave.

Steps

  1. Have your healthcare provider complete the applicable form — ADA Leave Accommodation Request Form for a medical condition, or PWFA Leave Accommodation Request Form for pregnancy, childbirth, or a related condition.
  2. Ensure it's signed and includes all necessary information, such as leave dates and the need for leave.
  3. Submit the form to begin the interactive dialogue with your employer.

What if it doesn't work

  • I'm not sure which form applies to my situation: Contact your Leave Success Manager for guidance.
  • If none of these apply, contact your Leave Success Manager.

Limits and exceptions

  • The ADA form supports ADA leave only; the PWFA form supports PWFA leave only.
  • Each form must be signed by a healthcare provider to be valid.

Related questions

  • What documentation might I need to support my leave of absence?
  • What is a Non-FMLA medical certification?