Medical Inquiry Form / Accommodation Request
Employee Name: Date:
Job Evaluated:
Please answer and return the following questionnaire as soon as possible. A self-addressed, stamped envelope is
enclosed for your convenience. The questionnaire format is a guide and we would appreciate a response to every
question. We need your complete medical opinion, so please feel free to include a more detailed narrative response to
any and all questions, if needed, to answer more fully. Thank you for your anticipated cooperation.
IMPORTANT NOTE TO HEALTH CARE PROVIDER: When answering these questions, please do not take into consideration
any ameliorative effects of mitigating measures, such as medications, medical supplies, equipment, or appliances, low-
vision devices (which do not include ordinary eyeglasses or contact lenses), prosthetics including limbs and devices,
hearing aids and cochlear implants or other implantable hearing devices, mobility devices, or oxygen therapy equipment
and supplies; use of assistive technology; reasonable accommodations or auxiliary aids or services; or learned behavioral
or adaptive neurological modifications.
1. Does the employee have a physical or mental impairment? {circle one} Yes No
If so, please state the diagnosis code and type of impairment:
2. Does the employee‘s impairment substantially limit any of his/her major life activities? {circle one} Yes No
If so, which major life activity or activities are limited?
3. For each major life activity that is limited by the impairment, please describe how the employee is restricted as to
the condition, manner, or duration under which that activity can be performed, as compared to the way in which
an average person in the general population can perform that activity:
4. What is the duration or expected duration of the employee’s impairment?
5. Attached is a job description for the employee’s position. In addition to the attached job description, essential
functions of this position also include the following:
Being available and able to complete all required essential functions and assigned job tasks during the
company’s normal business hours of 8:00 a.m. – 5:00 p.m.
Consistent and timely attendance.
Other:
**Once you have reviewed the job description and the list of additional, specific job functions above, please assess
whether the employee can perform all of these job functions and explain below which functions, if any, s/he is not
able to perform:
