FORM RA1
HUMAN RESOURCES
REASONABLE ADJUSTMENT AND
SPECIAL CONSIDERATIONS FORM
Employee Name:
Department
Line Manager
Date Form Completed
HR Adviser
Occupational Health
Adviser
Confidentiality
The University is mindful that any disclosure of a disability/long term illness or condition that impacts
an individual is confidential. In order to support the employee to perform the duties of their role, it
may be essential to put reasonable adjustments in place and consequently the immediate line
manager and other employees that have a need to know (for example: Link HR Adviser) may, with the
employee’s consent, be informed of the adjustments in place.
This form is for the employee and the current and any future line manager to work in partnership to
ascertain the required adjustments needed to support the employee in performing their duties.
Workplace Adjustment Agreement
This form is a record of the reasonable adjustments agreed between [employee’s name] and [line
manager’s name] as recommended by Occupational Health.
This document may be reviewed and amended as necessary with the agreement of both parties in a
variety of meetings including:
 At any regular one-to-one meeting
 At a return to work meeting following a period of sickness/disability related absence.
 Before a change of job or duties or introduction of new technology or ways of working.
 Before or after any change in disability/work circumstances for either party.
Page 1 of 4
PART 1: This section should be completed by the employee:
Type of Disability/Illness (physical and/or psychological – if you do not wish to disclose the exact nature of your illness,
please use general phases to imply something which impacts wellbeing or mental health – for example: if you have dyslexia
this could be referred to as a Specific Learning Difficulties (SpLD)
How long has the condition been present: ………………………………….
Please confirm if this is permanent [
] or temporary [
] (tick as appropriate)
Adjustment Agreement
Impact
My disability has the following impact on me:
On a ‘good day’ my disability has the following impact on me:
On a ‘bad day’, the following behaviour/symptoms are indications that I am not well:
Where applicable the ‘triggers’ for me becoming unwell are (include work and other triggers):
How often does your illness/disability impact on your ability to attend work? (this can be unpredictable, but
please state on average)
Page 2 of 4
Reasonable Adjustments/Considerations
Taking into account your duties and responsibilities what adjustments/considerations could the University
provide to support you?
Please pass to your line manager prior to your meeting to discuss possible adjustments, as further
advice may be required to inform the meeting.
Page 3 of 4
PART 2: Adjustments – to be completed by Line Manager & Employee
Has advice been sought from anyone else? (if relevant, attach any applicable documentation)
Occupational Health
Comments:
[Yes] [No] [NA] Date: ………………………..
GP / Specialist
Comments:
[Yes] [No] [NA] Date: ………………………..
Access to work
Comments:
[Yes] [No] [NA] Date: ………………………..
Other:
Adjustments – to be completed by Line Manager & Employee
(a) Please list the adjustments that are to be put in place and if they
are temporary, permanent or on a trial basis.
(b) If some adjustments have been made but have been
unsuccessful, please specify details.
(c) If adjustments were recommended, but the department has been
unable to implement the adjustment, please specify details.
Review Date(s)
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
Continue as necessary
I will communicate to my line manager if there are changes to my condition which will have an effect
on my work and/or if the agreed adjustments are not working. This will result in us meeting privately
to discuss any further reasonable adjustments or changes that should be made.
Employee Signature:
Line Manager Signature:
--------------------------------------------------------------
-----------------------------------------------------------
Date: ------------------------------------------------------
Date: ---------------------------------------------------
Page 4 of 4