Letter Requesting Documentation For Determining Ada Eligibility From A Medical Provider Page 3

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Medical Inquiry Form in Response to an ADA Reasonable Accommodation Request
Page 2
Major Bodily Functions: (check all that apply)
Bladder
Endocrine
Neurological
Bowel
Genitourinary
Normal Cell Growth
Brain
Hemic
Operation of an Organ
Cardiovascular
Immune
Reproductive
Circulatory
Lymphatic
Respiratory
Digestive
Musculoskeletal
Special Sense Organs
Other:
3. Duration: Describe the nature, severity and anticipated duration of the impairment.
Temporary (explain):
Anticipated duration:
Temporary with residual side effects (explain):
Permanent (explain):
Chronic (explain):
Questions to help determine whether an accommodation is needed.
An employee with a disability is entitled to an accommodation only when the
accommodation is needed because of the disability. The following questions may help
determine whether the requested accommodation is needed because of the disability.
1. What limitation(s) is interfering with job performance or accessing a benefit of
employment?
2. What job functions or benefits of employment is the employee having trouble
performing or accessing because of the limitation(s)?
3. How does the employee’s limitation(s) interfere with his/her ability to perform the job
function(s) or access a benefit of employment?

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