MEDICAL INQUIRY FORM TO CONFIRM DISABILITY OR NEED FOR ACCOMMODATION UNDER THE AMERICANS WITH DISABILITIES ACT (ADA) Important: Use this form only if the requesting employee's disability or need for an accommodation is not obvious, and the

Created by Jorge Rivero, Modified on Fri, 07 Oct 2022 at 10:44 AM by Jorge Rivero

MEDICAL INQUIRY FORM TO CONFIRM DISABILITY OR NEED FOR ACCOMMODATION UNDER THE AMERICANS WITH DISABILITIES ACT (ADA)

Important: Use this form only if the requesting employee's disability or need for an accommodation is not obvious, and the requesting employee has not already provided adequate information to confirm the disability or need for an accommodation

Employee name: ________________________________________

Impairment identified by employee: ____________________________________

Instructions to Healthcare or Rehabilitation Professional Completing this Form:

This form seeks information solely to (employer to check one or both):

	The existence of an ADA disability
	The need for an accommodation

Please complete only the parts of this form checked above, and please do not provide any information beyond what is necessary to make this assessment. Furthermore, please do not provide information relating to any medical condition that does not require accommodation.

As directed by the ADA, you should assess the ability of the individual to perform a major life activity as compared to most people in the general population. Do not consider mitigating measures (for example, hearing aids), with the exception of ordinary eyeglasses or contact lenses. If the impairment is episodic or in remission, evaluate whether the impairment would substantially limit a major life activity when active.

Information to Determine the Existence of Disability

Does the individual have a physical or mental impairment?	Yes	No
Does the individual have a record of a physical or mental impairment?		Yes	No
If so, please identify and describe the impairment (including the nature, severity, and duration of the impairment): ________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Does the impairment substantially limit a major life activity?	Yes	No
If so, check any major life activity that is substantially limited:

	Caring for oneself	Performing manual tasks	Seeing
	Hearing	Eating	Sleeping
	Walking	Standing	Lifting
	Bending	Speaking	Breathing
	Learning	Reading	Concentrating
	Thinking	Communicating	Working
	Sitting	Reaching	Interacting with others
	Operation of a major bodily function (see below)	Other:_______________________________ ____________________________________
If applicable, check any major bodily function that is substantially limited:

	Immune system	Special sense organs and skin	Normal cell growth
	Digestive functions	Genitourinary functions	Bowel functions
	Bladder functions	Neurological functions	Cardiovascular functions
	Endocrine functions	Hemic functions	Lymphatic functions
	Musculoskeletal functions	Reproductive functions	Operation of an individual organ: ________________
	Other: ______________________________________
Explain how the individual's impairment substantially limits any major life activity identified above: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Information to Determine Need for Accommodation

Does this individual have difficulty performing a job function?	Yes	No
If yes, please explain: ______________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Does this individual have difficulty accessing an employment benefit?		Yes	No
If yes, please explain: ______________________________________________________ ________________________________________________________________________ ________________________________________________________________________
What limitation, if any, is interfering with the individual's ability to perform the employee's job functions or access an employment benefit? ________________________ ________________________________________________________________________ ________________________________________________________________________
Please suggest any possible workplace accommodation(s) you believe will help with the difficulty or difficulties identified above: _______________________________________ ________________________________________________________________________ ________________________________________________________________________
How would any suggested accommodation help this individual perform the individual's job functions or access an employment benefit? __________________________________ ________________________________________________________________________ ________________________________________________________________________

Safe Harbor Provision Under GINA

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.

Print Name of Healthcare or Rehabilitation Professional:

__________________________________________________

Signature of Healthcare or Rehabilitation Professional:

__________________________________________________

Date: __________________