Request For Medical Information For Reasonable Accommodation Form

TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER

REQUEST FOR MEDICAL INFORMATION FOR REASONABLE ACCOMMODATION

DATE:

______________________

TO:

________________________________________________________________________________

(Physician or Medical Provider)

FROM:

________________________________________________________________________________

(Employee Name)

(Tech ID - R#)

SUBJECT:

REQUEST FOR MEDICAL INFORMATION NEEDED TO ASSIST IN PROVIDING A REASONABLE

ACCOMMODATION:

I have requested a reasonable accommodation from my employer, Texas Tech University Health Sciences Center, to assist in

providing employment or participation in a program, activity, or service. The information requested below is confidential and will

only be used to determine the specific equipment and/or services necessary to accommodate the identified limitations due to the

verified disability. 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.

Under the Americans with Disabilities Act and the Americans with Disabilities Act Amendments Act, an individual with a disability is

a person who:

•

Has a physical or mental impairment that substantially limits one or more major life activities (major life activity may include,

but is not limited to, walking, breathing, speaking, performing a manual task, seeing, hearing, learning, caring for oneself, sitting,

standing, lifting, or reading);

•

Has a record of such an impairment; or

•

Is regarded as having such impairment.

Please take the above definition into consideration and answer the following questions with respect to the Employee’s request for

reasonable accommodation:

1. Does the individual have an impairment that limits a major life activity?

___ YES

___ NO

If yes, please see the second page of this form to describe the limitation.

2. Is the disability permanent? ___ YES

___ NO

Length of anticipated duration _______________________________

3. From the enclosed job description, specify the job duty that the employee cannot perform _____________________________

_______________________________________________________________________________________________________

4. How does the limitation(s), impair the ability of the Employee to perform the job duty described above?

________________________________________________________________________________________________________

___________________________________________________________________________(______)__________________________

Physician’s Signature

Date

Phone

ATTACHMENT B

Page 1 of 2

HSC OP 10.15

November 26, 2014

Request For Medical Information For Reasonable Accommodation Form - 2014

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