Sample medical inquiry form in response to an


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SAMPLE MEDICAL INQUIRY FORM IN RESPONSE TO AN

A. Questions to help determine whether an employee has a disability.

A person has a disability under the ADA if the person has an impairment that substantially limits one or more major life activities. The following questions may help determine whether an employee has a disability:

Does the employee have a physical or mental impairment?

Yes

No
















What is the impairment?

______________________________
















Is the impairment long-term or permanent?

Yes

No



















If not permanent, how long will the impairment likely last?

______________________________
















Does the impairment affect a major life activity?

Yes

No













If yes, what major life activity(s) is/are affected?













  • Caring For Self

  • Interacting With Others

  • Performing Manual Tasks

  • Breathing

  • Working




  • Walking

  • Standing

  • Reaching

  • Thinking

  • Toileting




  • Hearing

  • Seeing

  • Speaking

  • Learning

  • Sitting




  • Lifting

  • Sleeping

  • Concentrating

  • Learning

  • Reproduction




  • Other: (describe)















Is the employee substantially limited in one or more of these major life activities?

Yes

No

B. 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:

What limitation(s) is interfering with job performance?


What job function(s) is the employee having trouble performing because of the limitation(s)?


How does the employee’s limitation(s) interfere with his/her ability to perform the job function(s)?


ACCOMMODATION REQUEST

(Page 2 of 2)

C. Questions to help determine effective accommodation options.

If an employee has a disability and needs an 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:

Do you have any suggestions regarding possible accommodations to improve job performance? If so, what are they?



How would your suggestions improve the employee’s job performance?



D. Comments.




SAMPLE MEDICAL INQUIRY FORM IN RESPONSE TO AN

ACCOMMODATION REQUEST


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