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Disability Accommodation Form

The disability accommodation form helps employees and candidates with disabilities request reasonable accommodation so they can work on an equal basis. It identifies barriers in the workplace, records the agreed assistive technology, accessibility or schedule changes, includes a personal emergency evacuation plan, and sets review dates.

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[Company Logo][Company Name]

DISABILITY ACCOMMODATION FORM

Ref. No.:: [Reference Number]
Date:: [DD/MM/YYYY]
Classification:: Confidential

Part 1 – Employee Details

Employee / Candidate Name
Employee ID
Designation
Department
Work Location
Reporting Manager

Part 2 – Disclosure (voluntary)

Nature of disability (optional, in your words)
UDID / disability certificate available (Yes / No / Prefer not to say)
Preferred format for communication (large print, email, sign language interpreter, other)

Part 3 – Barriers at Work

Area	Barrier Faced	Suggested Solution
Physical access (entry, lift, toilet, desk)	[Details]	[Suggestion]
Digital (software, portals, documents)	[Details]	[Suggestion]
Communication (meetings, training)	[Details]	[Suggestion]
Schedule / workload / travel	[Details]	[Suggestion]
Commute / parking	[Details]	[Suggestion]

Part 4 – Agreed Accommodation Plan

Accommodation	Owner	Cost (₹)	Target Date	Status
[Assistive technology, e.g., screen reader]	[IT]	[Amount]	[DD/MM/YYYY]	[Open / Done]
[Accessibility change, e.g., ramp, desk height]	[Admin]	[Amount]	[DD/MM/YYYY]	[Open / Done]
[Schedule change, e.g., flexible start]	[Reporting Manager]	[Amount]	[DD/MM/YYYY]	[Open / Done]

Part 5 – Personal Emergency Evacuation Plan

Alarm alert method (visual / vibrating / buddy)
Evacuation buddy and alternate
Route and refuge point
Equipment needed (evacuation chair, other)
Shared with safety marshals on [DD/MM/YYYY]

Part 6 – Review

Next review date
Grievance Redressal Officer	[Name], [Email]

Declaration and Consent

I agree to the accommodation plan above and consent to relevant details being shared only with the people named as owners and the safety marshals for my evacuation plan. I may request a review at any time.

Employee
[Employee Name]
Date: [Date]

HR
[HR Name]
Date: [Date]

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What this template includes

Voluntary disclosure with optional UDID or disability certificate
Barrier identification across physical, digital, communication and schedule
Accommodation plan with owner, cost and date
Assistive technology and accessible software
Personal emergency evacuation plan (PEEP)
Link to the company's Grievance Redressal Officer or equal opportunity policy

When to use it

Onboarding a new joiner who is a person with disability
An existing employee acquires a disability or a condition progresses
Office moves or new systems that may create new barriers
Annual review of agreed accommodations

How to customise this template

1Insert your Equal Opportunity Policy reference and grievance officer name
2Ask your IT team to list available assistive tools (screen readers, captioning)
3Work with admin on ramps, accessible toilets and parking
4Agree the evacuation buddy and route with safety marshals
5Set a review cycle and keep the plan confidential

HR tips

Ask the employee what works for them; they know best
Many accommodations cost little, such as seating changes or flexible hours
Test digital tools for screen-reader compatibility
Never share disability details beyond those who need to know

Establishments have duties on reasonable accommodation and non-discrimination under the Rights of Persons with Disabilities Act, 2016 and its rules; verify the obligations that apply to your organisation and review with a legal adviser.

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Frequently asked questions

What is reasonable accommodation under the RPwD Act?+

It means necessary and appropriate modifications and adjustments, without a disproportionate or undue burden, to ensure persons with disabilities enjoy rights equally with others.

Is a disability certificate required to request accommodation?+

The company may ask for reasonable supporting information, and a UDID or disability certificate is common. Many accommodations can be made without one; avoid delaying simple adjustments.

What is a personal emergency evacuation plan?+

A PEEP is an individual plan for safely evacuating a person who may need help in an emergency, naming buddies, routes and equipment.

All 50 posh, workplace safety & compliance →

[Company Logo][Company Name]
COMPLAINT OF SEXUAL HARASSMENT AT THE WORKPLACE
To,
The Presiding Officer
Internal Committee, [Company Name]
[Company Address]
Email: [IC Email Address]

This form is confidential. You may attach additional sheets wherever space is insufficient.
Part A – Complainant Details
Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you
Part B – Respondent Details
Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)
Part C – Details of the Incident(s)
Form · Word
POSH Complaint Form
Download .docx
[Company Logo][Company Name]
POSH TRAINING FEEDBACK FORM
Session Date:
[DD/MM/YYYY]
Trainer:
[Trainer Name]
Batch / Location:
[Work Location]
Your feedback helps us improve. Writing your name is optional. Please do not use this form to report a complaint; contact the Internal Committee at [IC Email Address] or any committee member instead.
Section A – About You (optional)
Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff
Section B – Rate the Session (1 = Poor, 5 = Excellent)
Aspect 1 2 3 4 5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me
Form · Word
POSH Training Feedback Form
Download .docx
[Company Logo][Company Name]
WORKPLACE SAFETY INCIDENT REPORT
Incident No.:
[Reference Number]
Date of Report:
[Date]
Reported by:
[Employee Name], [Designation]
Part 1 – Incident Details
Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department
- Fire / smoke / explosion
- Electrical incident
- Chemical / gas / oil leak or spill
- Equipment, vehicle or machine failure
- Structural failure / falling object
- Injury to person (attach injury report)
- Property damage only
- Other: [Details]
Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)
Part 2 – Immediate Action
Form · Word
Workplace Safety Incident Form
Download .docx
[Company Logo][Company Name]
ACCIDENT REPORT FORM
Report No.:
[Reference Number]
Establishment:
[Company Name], [Work Location]
Date of Report:
[Date]
A. Injured Person
Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)
B. Accident Details
Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time
C. Injury Details
Form · Word
Accident Report Form
Download .docx
[Company Logo][Company Name]
FIRST AID INCIDENT FORM
Form No.:
[Reference Number]
Date:
[DD/MM/YYYY]
Time:
[Time]
Location:
[Work Location]
Person Treated
Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number
Complaint or Injury
- Cut / abrasion
- Burn
- Sprain / strain
- Eye irritation / foreign body
- Fainting / dizziness
- Headache / fever
- Allergic reaction / insect bite
- Other: [Details]
Brief description of what happened
Work-related? (Yes / No)
Body part affected
Form · Word
First Aid Incident Form
Download .docx

Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you

Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)

Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff

Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department

Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)

Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)

Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time

Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number

Brief description of what happened
Work-related? (Yes / No)
Body part affected

[Company Logo][Company Name]

PRE-EMPLOYMENT MEDICAL EXAMINATION FORM

Form No.:: [Reference Number]
Date:: [DD/MM/YYYY]
Clinic / Doctor:: [Clinic Name]

Part 1 – Candidate Details (to be filled by HR)

Candidate Name
Date of Birth
Gender
Designation Offered
Department
Work Location
Expected Date of Joining
Job exposures (noise / dust / chemicals / heat / height / driving / night shift / food handling)

Part 2 – Health Questionnaire (to be filled by Candidate)

Question	Yes / No	Details
Any ongoing medical condition relevant to the job?		[Details]
Any surgery or hospitalisation in the last [Number] years?		[Details]
Regular medicines currently taken?		[Details]
Any hearing, vision or breathing difficulty?		[Details]
Any back, joint or mobility issue?		[Details]
Any allergy (medicines, dust, chemicals)?		[Details]
Any workplace adjustment you would like us to consider?		[Details]

Part 3 – Clinical Examination (Doctor)

Form · Word

Pre-Employment Medical Form

Download .docx

[Company Logo][Company Name]

ANNUAL / PERIODIC MEDICAL EXAMINATION FORM

Form No.:: [Reference Number]
Examination Year:: [Year]
Date:: [DD/MM/YYYY]
Examining Doctor:: Dr. [Doctor Name]

Section 1 – Employee and Exposure Details

Employee Name
Employee ID
Designation
Department / Section
Date of Joining
Main exposures this year (noise / dust / chemicals / heat / vibration / night shift / screen work)
Average working hours per week
PPE used regularly

Section 2 – Interval Health History

Since the last exam, have you had…	Yes / No	Details
New or worsening cough or breathlessness?		[Details]
Ringing in ears or difficulty hearing?		[Details]
Skin rashes or irritation?		[Details]
Back, neck or joint pain?		[Details]
Eye strain or headaches?		[Details]
Work injuries or sick leave over [Number] days?		[Details]

Section 3 – Year-on-Year Comparison

Form · Word

Annual Medical Examination Form

Download .docx

[Company Logo][Company Name]
WORKPLACE ACCOMMODATION REQUEST
Request No.:
[Reference Number]
Date of Request:
[DD/MM/YYYY]
Section 1 – Employee Details
Employee Name
Employee ID
Designation
Department
Reporting Manager
Work Location
Shift / Work Pattern
Section 2 – Reason for Request
- Pregnancy or post-natal
- Temporary injury or recovery
- Long-term health condition
- Disability (also see disability accommodation form)
- Caregiving responsibility
- Religious practice
- Other: [Details]
You do not need to disclose a diagnosis. Please describe how your current work arrangements affect you.
Form · Word
Workplace Accommodation Request
Download .docx

Aspect	1	2	3	4	5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me

Disability Accommodation Form

Preview of the form

Part 1 – Employee Details

Part 2 – Disclosure (voluntary)

Part 3 – Barriers at Work

Part 4 – Agreed Accommodation Plan

Part 5 – Personal Emergency Evacuation Plan

Part 6 – Review

Declaration and Consent

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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