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?
2. If you answered “yes” to question #1, is your patient able to perform Yes
each of the essential job functions described without reasonable
3. If you answered “no” to question #2, would your patient be able to perform Yes
each of the essential job functions described with reasonable
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).
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.