"Medical Questionnaire in Support of Accommodation Request" - Delaware

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MEDICAL QUESTIONNAIRE IN SUPPORT OF ACCOMMODATION REQUEST
The purpose of this form is to make a determination about whether an employee has a disability that
qualifies for an accommodation consistent with the Americans with Disabilities Act (ADA) and must be
completed by the treating medical provider. The ADA provides for reasonable accommodations for
qualifying employees to perform the essential functions of their jobs and also provides reasonable
accommodations for other benefits and privileges of employment (e.g. training development,
recognition activities). Not all requests for accommodations require a completed medical questionnaire
(e.g. when both the disability and need for accommodation are obvious or when the employee has
already provided sufficient information to document the existence of the disability and functional
limitations relating to the essential functions of the job).
Employee Name: __________________________
1. Have you examined employee? Yes
No
If YES, date of last Examination: __________________
2. Does the employee have a “physical or mental” impairment interfering with the employee’s
ability to perform the essential functions of the job or access a benefit or privilege of
employment? Yes
No
(The ADA defines “physical or mental impairment” as any physiological disorder or condition, cosmetic
disfigurement, or anatomical loss affecting one or more body systems, such as neurological,
musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive,
digestive, genitourinary, immune, circulatory, hemic, lymphatic, skin and endocrine and any mental or
psychological disorder, such as intellectual disability (formerly termed mental retardation), organic brain
syndrome, emotional or mental illness, and specific learning disabilities.
This list of examples is not
exhaustive).
3. Does the physical or mental impairment impact any “major life activity” of the employee?
Yes
No
(The ADA defines “major life activities” as the basic activities that the average person in the general
population can perform with little or no difficulty, such as caring for oneself, performing manual tasks,
walking, seeing, hearing, speaking, breathing, learning, sitting, standing, lifting, and reaching. Major life
activities also include the operation of major bodily functions including but not limited to immune, normal
cell growth, digestive, bowel, bladder, genitourinary, hemic, special sense organs and skin, lymphatic,
neurological, brain, respiratory, circulatory, endocrine, reproductive, musculoskeletal, special sense
organs, cardiovascular. This list of examples is not exhaustive).
a. If you answered YES to #3, please identify the specific major life activity/activities impacted:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
MEDICAL QUESTIONNAIRE IN SUPPORT OF ACCOMMODATION REQUEST
The purpose of this form is to make a determination about whether an employee has a disability that
qualifies for an accommodation consistent with the Americans with Disabilities Act (ADA) and must be
completed by the treating medical provider. The ADA provides for reasonable accommodations for
qualifying employees to perform the essential functions of their jobs and also provides reasonable
accommodations for other benefits and privileges of employment (e.g. training development,
recognition activities). Not all requests for accommodations require a completed medical questionnaire
(e.g. when both the disability and need for accommodation are obvious or when the employee has
already provided sufficient information to document the existence of the disability and functional
limitations relating to the essential functions of the job).
Employee Name: __________________________
1. Have you examined employee? Yes
No
If YES, date of last Examination: __________________
2. Does the employee have a “physical or mental” impairment interfering with the employee’s
ability to perform the essential functions of the job or access a benefit or privilege of
employment? Yes
No
(The ADA defines “physical or mental impairment” as any physiological disorder or condition, cosmetic
disfigurement, or anatomical loss affecting one or more body systems, such as neurological,
musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive,
digestive, genitourinary, immune, circulatory, hemic, lymphatic, skin and endocrine and any mental or
psychological disorder, such as intellectual disability (formerly termed mental retardation), organic brain
syndrome, emotional or mental illness, and specific learning disabilities.
This list of examples is not
exhaustive).
3. Does the physical or mental impairment impact any “major life activity” of the employee?
Yes
No
(The ADA defines “major life activities” as the basic activities that the average person in the general
population can perform with little or no difficulty, such as caring for oneself, performing manual tasks,
walking, seeing, hearing, speaking, breathing, learning, sitting, standing, lifting, and reaching. Major life
activities also include the operation of major bodily functions including but not limited to immune, normal
cell growth, digestive, bowel, bladder, genitourinary, hemic, special sense organs and skin, lymphatic,
neurological, brain, respiratory, circulatory, endocrine, reproductive, musculoskeletal, special sense
organs, cardiovascular. This list of examples is not exhaustive).
a. If you answered YES to #3, please identify the specific major life activity/activities impacted:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
4. With respect to a major life activity identified in your response to #3a, is the employee
substantially limited in such activity?
Yes
No
(“Substantially limited” means the employee is unable to perform the activity, or substantially limited in
the manner or duration under which he/she can perform the activity, as compared to the ability or the
average person in the general population).
Compare the employee to most people in the general population.
The impairment need not prevent or severely restrict.
Consider the limitation as if the condition is in active state. Mitigating measures should not
be considered. (e.g. medication, medical equipment and devices, prosthetic limbs, low vision
devices, hearing aids, mobility devices)
5. Is the substantial limitation temporary or permanent? ____________________ (Note:
Does
not need to significantly or severely restrict to meet this standard.) If temporary, what is the
anticipated duration of the impairment? ___________________________________________
6. Can the employee perform the essential functions of the position WITH a Reasonable
Accommodation? (See attached description of essential job function). Yes
No
a. If you answered YES to #6:
i. Which job functions require an accommodation?
_________________________________________________________________
_________________________________________________________________
ii. What accommodation(s) is/are recommended?
_________________________________________________________________
_________________________________________________________________
iii. How will the accommodation(s) enable the employee to perform the essential
functions of the position or access a benefit or privilege of employment?
_________________________________________________________________
_________________________________________________________________
_______________________________________
____________________
Signature of Medical Provider
Date
Provider’s Name:
____________________________________
Address:
_______________________________________________________________
Phone Number:
________________________
Fax Number:
_________________
_____________________________
_____________________
Employee Signature
Date
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