MEDICAL QUESTIONNAIRE
For Reasonable Accommodation Request
Page 1 of 4
This form is to be completed by the medical provider of a City of Chicago employee, job applicant, or volunteer. Please be as
detailed as possible in your answers. Please fax the completed form to Jennifer Smith, Disability Officer, at (312) 744-
9710. You may attach additional paper if more room is needed to fully answer a question. Please sign and date all pages attached
to this form. If you have any questions, please call Jennifer Smith, Disability Officer, at (312) 744-4969.
YOUR PATIENT -- OUR EMPLOYEE/APPLICANT/VOLUNTEER
Name: ___
_____________________________________________________________________________________________________
Job Title: _______________________________________________________________ Date of Birth: _________________________
Home Phone: _____________________________________________ Work Phone: ______________________________________
Department: _____________________________________________ Bureau/Division: ___________________________________
QUESTIONS TO DOCUMENT THE REASON FOR THE REQUEST
Does the employee/applicant/volunteer have a physical or mental impairment? If so, please identify and describe the physical or
mental impairment. An “impairment” could include an injury to the human body.
Based on reasonable medical certainty, is the impairment permanent?
_______ Yes ______ No
If “No”, please state the length of anticipated duration and/or prognosis: _________________________________________________
______________________________________________________________________________________________________________
Does the physical or mental impairment, when active, substantially limit a major life activity or a major bodily function of the
employee/applicant/volunteer?
______ Yes ______ No
If yes, please identify all major life activities or bodily functions that are limited by using the check boxes below:
Major Life Activities: Please check all that apply. Use the space below to list any major life activities not listed.
______ Eating ______ Lifting
______ Standing ______ Bending
______ Walking ______ Concentrating
______ Breathing ______ Learning
______ Seeing ______ Speaking
______ Pushing ______ Hearing
______ Reaching
______ Sitting
Other________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
