Letter Requesting Documentation For Determining Ada Eligibility From A Medical Provider Page 4

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Medical Inquiry Form in Response to an ADA Reasonable Accommodation Request
Page 3
An individual with a record of a substantially limiting impairment may be entitled, absent
undue hardship, to a reasonable accommodation if needed and related to the past disability.
1. What past 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 past limitation(s)?
3. How does the employee’s past limitation(s) interfere with his/her ability to perform the
job function(s) or access a benefit of employment?
Question to help determine effective accommodation options.
If an employee has a disability and needs an effective accommodation because of the
disability, the employer must provide a reasonable accommodation, unless the
accommodation poses an undue hardship. The following questions may help determine
effective accommodations:
1. Do you have any suggestions regarding possible accommodations that are needed to
improve job performance?
YES
NO
a. If so, what are they?
2. How would your suggestions improve the employee’s job performance?

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