STATE OF GEORGIA

[Agency Name]

REASONABLE ACCOMMODATION REQUEST

Health Care Provider Information

Documentation in Support of Request

Attached to this form are the current job description and essential functions of the position held by [employee name]. Please answer the following questions regarding the employee’s condition as it relates to the essential functions and possible workplace accommodations. The employee’s signed Medical Release is also attached.

This information is requested so that [agency/department] can properly evaluate this employee’s workplace accommodation request(s).

Does the employee have a mental or physical impairment that substantially limits a major life activity? If so, describe the impairment and its impact on this individual’s major life activities. (Major life activities include, but are not limited to, walking, seeing, hearing, speaking, breathing, learning, performing manual tasks, caring for oneself.)

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[Agency Name]

Health Care Provider Information

Documentation in Support of Request

Does the impairment affect the employee’s ability to perform one or more of the essential functions of the position? If so, please describe the impact on the person’s ability to perform specific functions.

Are there any workplace accommodations that you believe would allow the employee to perform the essential functions of the job? If so, describe those accommodations.

Is the need for accommodation likely to be temporary or permanent? If temporary, how long do you estimate the need for accommodation will exist?

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[Agency Name]

Health Care Provider Information

Documentation in Support of Request

Health Care Provider name Professional license or specialty

(Please Print)

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Signature Date