Medical 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 a medical accommodation, 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

Requested accommodation (job change, schedule change, dress/appearance code exception, vaccination exemption, etc.):

Length of time requested accommodation is needed:

Please provide your best guess as to how long you will need this accommodation: ie; 2 weeks, 1 month, indefinitely

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 condition(s) 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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have read and understand Mueller Family McDonald’s policy on medical accommodation. I understand that the accommodation requested above may not be granted but that the company will attempt to provide a reasonable accommodation that does not create an undue hardship on the company. I understand that Mueller Family McDonald’s may need to obtain supporting documentation regarding my medical condition to further evaluate my request for a medical accommodation.

Verification