Request For Medical Information For Reasonable Accommodation Form

Request For Medical Information For Reasonable Accommodation Form - 2014 Page 2

TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER

REQUEST FOR MEDICAL INFORMATION FOR REASONABLE ACCOMMODATION

Employee Name ________________________________________

Tech ID (R#) __________________________

Instructions: Complete this form only if the answer to question #1 is yes.

Work Restrictions: Patient is restricted from or limited in performing the following functions (check activity and enter

limitation, i.e.: 0 hours; 1-2 hours, 2-5 hours, 6-8 hours; or other notation);



KEYBOARD USE/REPETITIVE USE OF HANDS

GRASP/FINE FINGER MOTIONS



SIT

REPETITIVE USE OF FOOT CONTROLS



STAND

WALK



SQUAT/KNEEL

TWISTING (NECK/WAIST)



BEND/STOOP

CLIMB LADDERS/CLIMB STAIRS



PUSH/PULL

REACHING (Above and below shoulders)



LIFT (Please specify lifting restriction)

CARRY (Please specify carrying restriction)



OTHER

Describe any restrictions which may apply to the following:



VISION



HEARING



MENTAL/EMOTIONAL



OTHER (Sleeping, Speaking)

ATTACHMENT B

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HSC OP 10.15

November 26, 2014

Request For Medical Information For Reasonable Accommodation Form - 2014 Page 2