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ADA Accommodation Medical Certification

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

Note: This form should be customized each time it is used. Under the ADA, employers should only ask for necessary medical documentation. Do not ask for information you already have or do not need.

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

For 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 an impairment. The following questions may help determine whether an employee has a disability:


Does the employee have a physical or mental impairment?    Yes  /   No

If yes, what is the impairment or the nature of the impairment? 
Note: Some state laws may prohibit asking for a diagnosis.


Answer the following question based on what limitations the employee has when his or her condition is in an active state and what limitations the employee would have if no mitigating measures were used. Mitigating measures include things such as medication, medical supplies, equipment, hearing aids, mobility devices, the use of assistive 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 in appropriate cases 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.

Yes   /   No




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

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

  • Bending
  • Breathing
  • Caring For Self
  • Concentrating
  • Eating

  • Hearing
  • Interacting With Others
  • Learning
  • Lifting
  • Performing Manual Tasks

  • Reaching
  • Reading
  • Seeing
  • Sitting
  • Sleeping

  • Speaking
  • Standing
  • Thinking
  • Walking
  • Working

  • Other: (describe)


Major bodily functions:

  • Bladder
  • Bowel
  • Brain
  • Cardiovascular
  • Circulatory


  • Digestive
  • Endocrine
  • Genitourinary
  • Hemic
  • Immune

  • Lymphatic
  • Musculoskeletal
  • Neurological
  • Normal Cell Growth
  • Operation of an Organ

  • Reproductive
  • Respiratory
  • Special Sense Organs & Skin
  • Other: (describe)

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:

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?


C. Questions to help determine effective accommodation options.

If an employee has a disability and needs an accommodation because of the disability, the employer must provide a reasonable accommodation, unless the accommodation poses an undue hardship.  The following questions may help determine effective accommodations:


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.




Medical Professional's Signature:                                       Date:



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.


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