Fillable CERTIFICATION OF HEALTH CARE PROVIDER FOR REASONABLE ACCOMMODATION (Oral Roberts University)

Fill Online, Printable, Fillable, Blank CERTIFICATION OF HEALTH CARE PROVIDER FOR REASONABLE ACCOMMODATION (Oral Roberts University) Form

Use Fill to complete blank online ORAL ROBERTS UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CERTIFICATION OF HEALTH CARE PROVIDER FOR REASONABLE ACCOMMODATION (Oral Roberts University)

On average this form takes 4 minutes to complete

The CERTIFICATION OF HEALTH CARE PROVIDER FOR REASONABLE ACCOMMODATION (Oral Roberts University) form is 2 pages long and contains:

  • 0 signatures
  • 6 check-boxes
  • 12 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Oral Roberts University

BROWSE ORAL ROBERTS UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
CERTIFICATION OF HEALTH CARE PROVIDER
FOR REASONABLE ACCOMMODATION
Patient’s Name: ______________________________________________________________________
Date Condition Commenced: _____________________________________________________________
Probable Duration of Condition: __________________________________________________________
This certification will be used for the purpose of assessing whether your patient has a disability that would
benefit from a reasonable accommodation within the workplace. Please base your assessment on your
patient’s present abilities or limitations in performing the essential functions of his/her current position as
described to you.
1. Does your patient have a disability?
1
Yes No
2. If you answered “yes” to question #1, is your patient able to perform Yes
No
each of the essential job functions described without reasonable
accommodation(s)?
3. If you answered “no” to question #2, would your patient be able to perform Yes
No
each of the essential job functions described with reasonable
accommodation(s)?
4. If you answered “yes” to question #3, please provide the following information: a) state which essential
function(s) of the job require an accommodation; b) for each such essential function, state any
recommendations you have for reasonable accommodation(s) and if there is more than one
recommended accommodation, please describe all possible accommodations; c) explain why the
disability requires this accommodation to allow the employee to perform the essential function(s).
1
A disability is a physical or mental impairment that substantially limits one or more major life activities of such individual; a
record of such an impairment; or being regarded as having such an impairment. Major life activities include, but are not limited
to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking,
breathing, learning, reading, concentrating, thinking, communicating, and working. A major life activity also includes the
operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive,
bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions.
2
________________________________ ___________________________
Signature of Health Care Provider Date
THIS FORM SHOULD BE RETURNED DIRECTLY TO ORAL ROBERTS UNIVERSITY’S HUMAN
RESOURCES DEPARTMENT AT HR@ORU.EDU.
Type the name and address of the Health Care Provider completing this form:
Name: ______________________________________________________
Address: ____________________________________________________
____________________________________________________________
____________________________________________________________
Telephone: __________________________________________________
Facsimile: ___________________________________________________
E-mail Address: ______________________________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CERTIFICATION OF HEALTH CARE PROVIDER FOR REASONABLE ACCOMMODATION (Oral Roberts University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document