About this form

This form is confidential. Store it apart from the personnel file. Only people who need to act on it should see it.

You do not need to name a diagnosis. Describe what you find hard and what would help. The employer may ask for more information only if needs are unclear.

In Ontario, public sector employers and other employers with 50 or more employees must keep a written process for documented individual accommodation plans under AODA section 28. This form supports that process.

General information, not legal advice.

Part A: Employee section

Name: ________ Job title: ________ Department: ________ Manager: ________ Date: ________

Preferred way to receive this plan (tick one):

• Print
• Email
• Audio or read aloud
• Large print
• Other: ________

1. Which tasks are hard for you right now? Answer: ________

2. What happens when you do these tasks? Answer: ________

3. What would help? List tools, changes or supports. Answer: ________

4. Have you tried anything that worked before? Answer: ________

5. Would you like a representative in meetings about this request?

• No
• Yes. Name: ________

Employee signature: ________ Date: ________

Part B: Manager section

Date request received: ________ Date of first meeting: ________

Options discussed:

Common options to consider:

• Text-to-speech or speech-to-text software
• Instructions given verbally and in writing
• Extra time for reading-heavy tasks
• Templates and checklists for routine documents
• Quiet workspace or noise-cancelling headphones
• Proofreading support for external documents
• Meeting agendas and materials sent in advance

Accessible formats or communication supports provided: ________

Individual emergency response information needed?

• No
• Yes. Details: ________

If an option is not approved, state the reason in plain language: ________

Review date: ________

Manager signature: ________ Date: ________

Part C: Review

Is the plan working?

• Yes, no change
• Partly. Changes: ________
• No. New plan needed

Employee initials: ________ Manager initials: ________ Next review: ________