Fill - Free fillable Ada Request Form (Southwest Tennessee Community College) PDF form

ADA Request for

Accommodation Form

OFFICE OF EQUITY & COMPLIANCE

ADA MEDICAL CERTIFICATION

Note: The information sought on this form pertains only to the condition for which the employee is requesting accommodation under

the ADA

To be completed by employee

Employee Name

Social Security#

Job title

Department

Employee Signature

Date

To be completed by the Health Care Provider

INSTRUCTIONS: Attached is a copy of the employee’s job description which indicates the essential functions of the position

and includes the physical/mental demands and environmental conditions associated with the job. Please review the attached

job description and complete and sign this form. Also, on your official letterhead, please state the disability findings, showing

a correlation drawn from tests to the diagnosis, including the treatment plan. Also include an ultimate prognosis as to the

disability and/or condition. Please attach to this form and forward to: Southwest Tennessee Community College, Human

Resources Office, P.O. Box 780, Memphis, TN 38101-0780.

Physician Name:

Specialization/Type of Practice:

Address:

Phone:

Fax:

SECTION I

Questions to determine whether an employee has a qualifying disability. A person has a qualifying disability under the

ADA if the person has an impairment that substantially limits one or more major life activities.

1. Does the employee have a physical or mental impairment? Yes No

2. What is the impairment _________________________________________________________________________________

____________________________________________________________________________________________________

3. Is the impairment long-term or permanent Yes No

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

___________________________________________________________________________________________________

5. Is this condition considered a chronic condition which:

A. requires periodic visits for treatment by a health care provider? Yes No

B. continues over an extended period of time? Yes No

C. may cause episodic rather than a continuing period of incapacity? Yes No

6. Does the impairment mean that the employee is substantially limited

in one or more major life activities? Yes No

ADA MEDICAL CERTIFICATION Page 2

To be completed by the Health Care Provider

7. If yes, what major life activity(ies) is/are affected?

___ caring for self ___ walking ___ hearing ___ lifting

___ interacting with others ___ standing ___ seeing ___ sleeping

___ performing manual tasks ___ reaching ___ speaking ___ concentrating

___ breathing ___ thinking ___ learning ___ working

___ toileting ___ sitting ___ reproduction other ___________________

SECTION II

Questions to determine whether an accommodation is needed.

1. What functional limitation(s) in major life activities is/are interfering with this employee’s job performance?

__________________________________________________________________________________________________

2. Have any treatment, medications and/or other remedial measures been prescribed? Yes No

If yes, please list.

__________________________________________________________________________________________________

3. Are the above treatment, medications and/or other remedial measures prescribed

actually being used? Yes No

__________________________________________________________________________________________________

3. What job function(s) listed in the job description is the employee having trouble performing because of the limitation(s)?

__________________________________________________________________________________________________

4. How does the employee’s limitation(s) in major life activities interfere with his/her ability to perform the job functions

Listed in the attached job description?

__________________________________________________________________________________________________

5. With reference to the attached list of job tasks, please state whether the employee is able to perform each task without the

use of prescribed medication and/or remedial measures.

6. With reference to the attached list of job tasks, please state whether the employee is able to perform each task with the

use of prescribed medication and/or remedial measures.

SECTION III

Questions to determine effective accommodation options.

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

__________________________________________________________________________________________________

2. How would your suggestion(s) improve the employee’s performance?

__________________________________________________________________________________________________

ADA MEDICAL CERTIFICATION Page 3

To be completed by the Health Care Provider

______________________________________________________________________________________________________

SECTION IV

Comments:

__________________________________________________________________________________________________

SIGNATURE OF HEALTH CARE PROVIDER:

(Stamps and Designee Signature NOT accepted.)

__________________________________________________ Date _______________________________________

All information provided is confidential and will be retained in the employee’s medical file.

Please return the requested information to the [Department’s Name] by [Date], [Year], so that we may begin reviewing the

employee’s request. If you have questions or need additional information, please contact [Name and Title] at [Telephone

Number] or [Email Address].

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