Healthcare Provider Information Request for a Qualified Indvidual with a Disability
This form is to be completed by the employee's healthcare provider when requesting an accommodation for
disability under the American's with Disabilities Act.
Employee First Name: Employee Last Name Employee NSU ID:
Instructions to the Health Care Provider
A request for a reasonable accommodation has been made by the employee identified above.
In order to assist with the interactive process, we are requesting that you provide answers to the following questions
based on your medical expertise. The medical documentation you provide should identify the disability, the major life
activity that is affected and how it impacts your patient at work so that solutions can be explored.
With this in mind, please review the enclosed job description and identify the specific duties impacted by your
patient’s medical condition and describe how the medical conditions causes work-related problems.
Does the employee have a physical or mental impairment?
Yes No
If yes, what is the impairment or nature of the impairment?
Does the employee's impairment substantially limit a major life activity or major bodily functions as compared to
most people in the general population?
Yes No
If major life activity or activities are affected please select the activities from the menu below.
Bending Breathing Self Care
Concentrating Eating Learning
Hearing Interpersonal Interaction Lifting
Manual Dexterity Reaching Vision
Sitting Walking Sleeping
Speaking Standing Thinking
Working (job description)
Other
