Request for Accommodation
Medical Accommodation Request
This form is only for workplace accommodation requests related to a medical condition and/or disability and must be completed by the requesting Associate. CarMax provides reasonable accommodations to qualified applicants and Associates with disabilities to support equal access to work and the benefits and privileges of employment. This form begins the interactive process by understanding how a medical condition or disability impacts your ability to perform your job or access the workplace. You are not required to disclose your diagnosis. Please describe your limitations and how they affect your work. Additional information, including documentation from a health care provider, may be requested if needed. Accommodation is determined through an interactive process and is not guaranteed. Each request is reviewed individually to identify an effective and reasonable solution. If you have questions or need assistance completing this form, contact HRSupport@carmax.com. Please see the CarMax Reasonable Accommodation policy on CarMax World for additional details. For religious accommodation requests, Click Here
| Is your request related to a medical condition or disability that creates limitations in the workplace?
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| If your request is not related to a medical condition or disability, do not complete a Request for Medical Accommodation. Please contact HRSupport@carmax.com, for guidance on what resources are available to you.
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| Is this request related to leave?
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| If your request involves time off from work, a reduced schedule, or intermittent absences, call the CarMax Leave Administrator at (866) 415-3284 to understand leave your options.
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Associate or Candidate Information
The Job Accommodations team will communicate with you via email. Please monitor your email regularly for important updates and next steps.
Workplace Impact and Functional Limitations
Describe how your disability or medical condition impacts you in the workplace. Be specific, general statements may delay review.
| How does it affect you at work?
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| Explain how the limitation affects your ability to perform the duty, access the workplace, or receive the employment benefit or privilege.
Examples: “I cannot complete [job task]” or “I have difficulty doing [specific job task] at work” or “I have difficulty accessing or participating in [employment benefit or privilege]”.
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| What is affected?
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| Identify the specific job duty, workplace barrier, or benefit/privilege affected.
Examples: lifting tools or supplies, standing at the customer-service counter, conducting vehicle walkarounds.
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| What functional limitation(s) do you experience?
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| Describe what you experience.
Examples: pain, fatigue, cannot carry more than [weight] pounds, or difficulty concentrating.
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Accommodation Input
| What accommodations might help you do your job?
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| Describe any workplace changes or accommodation you believe may help address these limitations and enable you to perform your essential job functions or access employment benefits. If unsure, you may share ideas you would like to explore.
Examples may include but are not limited to equipment/workstation changes, schedule adjustments, additional breaks, and/or environmental modifications.
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| Start Date
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| When do you anticipate your limitations to start?
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| End Date
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| When do you anticipate your limitations will end? Leave blank if your condition is ongoing with no anticipated end date
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| Can you provide documentation?
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| Can you provide documentation from a health care professional regarding your impairment, functional limitations and your need for accommodation(s)?
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| If yes, please enter your Health Care Provider name. If no, please explain.
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Authorization
I authorize any licensed physician, or other certified medical provider to release to CarMax or its third-party Leaves Administrator, medical information pertinent to evaluate my request for job accommodation. I also authorize my medical providers, CarMax representatives, Leaves Administrator and other administrators to share and discuss my medical information with each other for the purpose of evaluating potential accommodation. I hereby acknowledge that I have the right to receive a copy of the medical information provided to CarMax or the Leaves Administrator.
I understand that by submitting my request for accommodation that the CarMax Job Accommodations Team will engage with me in the interactive process regarding my request. I understand the Job Accommodations Team will focus on understanding my functional limitations and potential workplace accommodation. I understand that I am not required to disclose my medical diagnosis.
IMPORTANT NOTICE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of employees or their family members, except as specifically allowed by GINA. To comply with this law, we are asking that you not provide any Genetic Information when responding to this request for medical information. “Genetic Information”, as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive service.
| Do you authorize as described above?
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