ADA: Accommodation Medical Certification

February 14, 2018

Dear Physician,

A request for an employment-related reasonable accommodation has been made by our employee __________________ (name). To assist us with this process, please complete the following questions below.

Please answer these questions to help determine disability and reasonable accommodation.   

1) Please review the attached job description. (If no job description is attached, please discuss the position with our employee to determine essential job duties.) Is the employee able to perform the essential job functions of this position with or without reasonable accommodation?    Yes  /   No

If yes, please continue to next question.

If no, how long will the employee be unable to perform these job duties? 

____ # of weeks       ____# of months         ____ permanently 

2) Does the employee have a physical or mental impairment?  

If yes, what is the impairment?


3) What limitations are interfering with job performance, and how do they affect the employee's ability to perform the job functions?


4) What adjustments to the work environment or position responsibilities would enable the employee to perform the essential functions of that position?


5) The employee's typical schedule is ____________________________________. What, if any, adjustments need to be made to the employee's work schedule to enable the employee to perform the essential functions of that position? 


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


7) How long will the employee need the reasonable accommodation? If unable to provide date, when will he or she be medically reevaluated?

Any additional comments or suggestions:

______________________________  _______________
Physician Name (Please Print)                 Date

Signature of physician completing form


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