MEDICAL QUESTIONNAIRE / HEALTHCARE PROVIDER STATEMENT
Employee (Patient) Name:
L#:
Our employee (your patient) name above has requested an accommodation to the College’s current COVID-19 safety policies
and procedures. At the present time, masks must be worn at all times while on College property except in outdoor settings
with social distancing and when indoors working along in closed spaces. Furthermore, based on CDC recommendations, the
College requires that masks consist of 2 or more layers and cover the nose and mouth and secure under the chin. In accordance
with these recommendations, the College is not currently allowing the use of gaiters or face shields.
Lane Community College is requesting your assistance in obtaining the information needed to explore reaso
nable
accommodations for your patient in compliance with the requirements of Title I of the Americans with Disabilities Act (ADA)
and the Fair Employment and Housing Act (FEHA), consistent with the organizational goals to assist disabled employees to
remain at work with reasonable accommodations whenever possible.
As part of this process, we would appreciate your assistance to help us ensure that we have a full and correct understanding
of any and all impacts the College’s current COVID-19 safety policies and procedures regarding face masks have on our
employee (your patient). To that end, we respectfully request that you complete the following medical questionnaire and
return it to us with 10 calendar days.
SECTION 1 - Based on the College’s face mask requirements, please respond to the following questions for the above-named
employee (patient).
1. Do they have a physical or mental impairment that limits their ability to wear a mask?
☐ NO, they do not have a physical or mental impairment that limits their ability to wear a mask based on the College’s
requirements outlined above. Please proceed to Section 2.
☐ YES, they have a physical and/or mental impairment that limits their ability to wear a mask
, based on the College’s
requirements outlined above.
2. Please provide the diagnosis code and type of impairment:
3. Without accommodation, does their prolonged use of a mask pose a significant risk of substantial harm to their health and safety?
☐ NO, prolonged use of a mask does not pose a significant risk of substantial harm to their health and safety.
☐ YES, prolonged use of a mask poses a significant risk of substantial harm to their health and safety.
4. What adverse physical and/or mental effects would the employee experience as a result of wearing a mask, based on the College’s
requirements outlined above, for a period not to exceed:
5 minutes:
15 minutes:
30 minutes:
60 minutes:
90 minutes:
120 minutes:
5. The above adverse physical and/or mental effects are:
☐ TEMPORARY through (date)
☐ PERMANENT
