Letter Requesting Documentation For Determining Ada Eligibility From A Medical Provider Page 2
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6Medical Inquiry Form in
Response to an ADA Reasonable Accommodation Request
Please complete each section and fax back your signed and dated original form using the contact
information below.
Questions to help determine whether the employee has a disability.
Existence of impairment: For reasonable accommodation under the ADA, the employee has a disability
if he or she has a physical or mental impairment that substantially limits one or more major life
activities or a record of such impairment.
1. Does the employee have a physical or mental impairment?
YES
NO
a. If yes, what is the impairment?
2. Does the employee have a record of a substantially limiting impairment and needs a reasonable
accommodation related to the past disability?
YES
NO
a. If yes, what was the impairment?
Limitations on major life activities: Answer the following question based on what limitations the
employee has when his or her condition is in an active state and what limitations the employee would
have without regard to the ameliorative effects of any mitigating measures. Mitigating measures
include, but are not limited to, things such as medication, medical supplies, equipment, hearing aids,
mobility devices, assistive technology, auxiliary aids or services, prosthetics, etc. You should consider
the ameliorative effects of ordinary eyeglasses or contact lenses, however, in determining whether an
impairment substantially limits a major life activity.
1. Does the impairment substantially limit a major life activity as compared to most people in the
general population?
YES
NO
2. If yes, what major life activity(s) (including major bodily functions) is/are affected?
Major Life Activities: (check all that apply)
Bending
Learning
Sitting
Breathing
Lifting
Sleeping
Caring for Self
Performing Manual
Speaking
Tasks
Concentrating
Standing
Reaching
Eating
Thinking
Reading
Hearing
Walking
Seeing
Interacting with Others
Working
Other: (Describe):
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