Letter Requesting Documentation For Determining Ada Eligibility From A Medical Provider Page 5

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Medical Inquiry Form in Response to an ADA Reasonable Accommodation Request
Page 4
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.
The following questions may help determine effective accommodations:
1. Do you have any suggestions regarding possible accommodations of the past disability
that are needed to improve job performance?
YES
NO
If so, what are they?
2. How would your suggestions improve the employee’s job performance?
3. Other Questions or Comments:
Health Care Provider Name:
Health Care Provider Address:
Health Care Provider Phone Number:
Health Care Provider Signature
Date
(Please print and sign)

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