ADA Accommodation Request Form

It is Mueller Family McDonald's intention to provide all employees with the help they need to be successful on the job. If you require an accommodation that falls under ADA (Americans with Disabilities Act), please complete the form below. Someone from Human Resources will contact you to set up a meeting to review your request within 5 business days of receiving this form.

Please select

Employee First / Last name

Email address

Phone number

Describe the nature, extent, and duration of your disability:

Describe the accommodations you believe are needed to enable you to perform the essential functions of this job:

Provide the name, address, telephone and fax numbers of your health care provider. The provider may receive a request from us for information regarding your impairment/disability and recommendations for accommodations.

Provider's First / Last name

Provider's Phone number

Provider's Fax number

Provider's Address

Attach any supporting documentation that may be helpful in evaluating this request for accommodation.

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I authorize the release of information regarding my disability to Mueller Family McDonald’s management as deemed necessary by Human Resources to facilitate this request for accommodation.

Verification