Medical Inquiry Form In Response to an Accommodation Request

  • Medical Inquiry Form In Response to an Accommodation Request

    Note: As related to reasonable accommodation under the ADA, an employee has a disability if he or she has an impairment that substantially limits one or more major life activities or a record of such impairment. The following questions are for the purpose of certification of disability and evaluating the request for accommodation submitted by the individual named below. Please complete and return via the following HIPAA compliant link.

  • A. Questions to help determine whether an employee has a disability.

  • Does the employee have a physical or mental impairment?*

  • Answer the following question based on what limitations the employee has when the condition is in an active state and what limitations the employee would have if no mitigating measures are used. Mitigating measures include things such as medication, medical supplies, equipment, hearing aids, mobility devices, the use of assitive technology, reasonable accommodations or auxiliary aids or services, prosthetics, learned behavioral or adaptive neurological modifications, psychotherapy, behavioral therapy, and physical therapy. Mitigating measures do not include ordinary eyeglasses or contact lenses.

  • Does the impairment substantially limit a major life activity as compared to most people in the general population? [Note: Does not need to significantly or severely restrict to meet this standard. It may be useful to consider the condition under which the individual performs the major life activity; the manner in which the individual performs the major life activity; and/or the duration of time it takes the individual to perform the major life activity, or for which the individual can perform the major life activity.]*
  • If yes to the above question, what major life activity(s) (includes major bodily functions) is/are affected?

  • B. Questions to help determine whether an accommodation is needed .

    An employee with a disability is entitled to an accommodation only when the accommodation is needed because of the disability. The following questions may help determine whether the requested accommodation is needed because of the disability:

  • C. Questions to help determine effective accommodation options.

    If an employee has a disability and needs accommodation because of the disability, the employer will provide a reasonable accommodation, unless the accommodation poses an undue hardship. The following questions may help determine effective accommodations:
  • Date*
     - -
  • Format: (000) 000-0000.

  • 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 an individual or family member of the individual, except as specifically allowed by this law. 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 services.

    This form is provided by The Job Accommodation Network (JAN), a service of the U.S. DOL's Office of Disability Employment Policy.

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