EMPLOYEE IDENTIFICATION
Employee Name	Employee ID
Division/Work Unit	Employee Job Title

Instructions: To be completed by the attending healthcare provider to assist with the reasonable accommodation review process under the Americans with Disabilities Act (ADA), as amended. Please provide information only about the impairment(s) for which the individual is requesting accommodation. Please do not include any genetic information.
HEALTHCARE PROVIDER IDENTIFICATION
Healthcare Provider Name	Board Certified Specialty
Address
Telephone Number	Date	Health Care Provider Signature (No Stamps Please)
Name of Person Completing this Form (please print)
MEDICAL INFORMATION
Does the employee have a physical or mental impairment?	Yes No
If yes, what is the impairment?
Is the impairment permanent?	Yes No
If not permanent, how long will the impairment likely continue?
Please identify the activities that are substantially limited by the impairment.
Please use the attached job description to respond to the items below.
Does the impairment prevent the employee from performing any job functions?	Yes No
If yes, what limitations resulting from the impairment are interfering with job performance?
Which job functions are affected by the limitations resulting from the impairment?
How do the limitations interfere with the employee’s ability to perform job functions?
Would performing any of the job functions result in a direct safety or health threat to the employee or others?	Yes No
If yes, please identify the threat and the job functions that would pose such a threat.
Are there any workplace accommodations that you believe would allow the employee to perform the essential functions of the job?	Yes No
If yes, describe those accommodations.
Please estimate how long the employee will likely need accommodation in order to perform the job functions.
Additional Comments
Thank you for your time and assistance

Please send completed form & supporting documents to:	HR or Approving Official

Address

City, State zip

FAX: xxx-xxx-xxxx

For additional information or assistance, you may contact XXXXXXXX at xxx-xxx-xxxx.