Attachment 6 "Certification of Health Care Provider - Ada" - Florida

This "Attachment 6 - Certification of Health Care Provider - Ada" is a part of the paperwork released by the Florida Department of Juvenile Justice specifically for Florida residents.

The latest fillable version of the document was released on February 1, 2011 and can be downloaded through the link below or found through the department's forms library.

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Download Attachment 6 "Certification of Health Care Provider - Ada" - Florida

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Attachment 6 
FDJJ 1060 – 6 
New 8/17/11 
 
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
AMERICANS WITH DISABILITIES ACT
CERTIFICATION OF HEALTH CARE PROVIDER - ADA
Once completed, please submit this form to your supervisor. Failure to do so
may result in the delay or denial of your request for ADA accommodation(s).
Date:
Employee’s Name:
Employee’s Title:
Employee’s Business Address:
City:
State:
Zip Code:
Employee’s Business Telephone Number:
Name of Physician or Health Care Provider:
Address of Physician or Health Care Provider
Telephone Number of Physician or Health Care Provider:
Employee’s Disability(ies):
1) Describe the employee’s/patient’s relevant information as it relates to the disability(ies) listed
above.
2) What is the probable duration of the disability(ies)?
3) What limitation(s) will the disability(ies) place upon the employee/patient ?
1
New 2/1/11
Attachment 6 
FDJJ 1060 – 6 
New 8/17/11 
 
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
AMERICANS WITH DISABILITIES ACT
CERTIFICATION OF HEALTH CARE PROVIDER - ADA
Once completed, please submit this form to your supervisor. Failure to do so
may result in the delay or denial of your request for ADA accommodation(s).
Date:
Employee’s Name:
Employee’s Title:
Employee’s Business Address:
City:
State:
Zip Code:
Employee’s Business Telephone Number:
Name of Physician or Health Care Provider:
Address of Physician or Health Care Provider
Telephone Number of Physician or Health Care Provider:
Employee’s Disability(ies):
1) Describe the employee’s/patient’s relevant information as it relates to the disability(ies) listed
above.
2) What is the probable duration of the disability(ies)?
3) What limitation(s) will the disability(ies) place upon the employee/patient ?
1
New 2/1/11
 
4) Based on the attached Department of Juvenile Justice position description, what
accommodation(s) are required in order for the employee/patient to successfully complete
his/her assigned tasks?
5) Please provide any other information that you feel is relevant in assessing the
employee’s/patient’s request for ADA accommodation(s).
CERTIFICATION OF HEALTH CARE PROVIDER
Signature of Health Care Provider
Type of Practice
Address
Telephone Number
City, State, Zip Code
Date
CERTIFICATION OF EMPLOYEE
Signature of Employee
Date
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and others 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.”
Attachments:
Protective Action Response (PAR) Responsibilities (When Applicable)
Position Description
2
New 2/1/11
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