Medical Inquiry Form In Response to an Accommodation Request

Patient Name for which you are providing this response:*

First NameLast Name

Does the employee have a physical or mental impairment?*

YesNo

If yes, what is the impairment or the nature of the impairment. Note that you do not need to provide actual diagnosis. Also, what is the expected duration of the impairment if not permanent?*

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.]*

YesNo

Describe the employee's limitations when the impairment is active.*

If yes to the above question, what major life activity(s) (includes major bodily functions) is/are affected?

If other, list here.

What limitation(s) is interfering with job performance or accessing a benefit of employment?*

What job function(s) or benefits of employment is the employee having trouble performing or accessing because of the limitation(s)?*

How does the employee's limitation(s) interfere with his/her ability to perform the job function(s) or access a benefit of employment?*

Do you have any suggestions regarding possible accommodations to improve job performance? If so, what are they? *

How would your suggestions improve the employee's job performance? *

D. Other questions or comments.*

Name*

First NameLast Name

Signature with Credentials (Do Not Type-Hand Draw Only)*

Date*

Date

Clinic/Practice Name and Location*

Phone Number*

Please enter a valid phone number.

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.

Medical Inquiry Form In Response to an Accommodation Request

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

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

C. Questions to help determine effective accommodation options.