Fillable Medical Questionnaire For Accommodation Request For Pregnancy, Childbirth, And Related Conditions (City of Chicago)

Fill Online, Printable, Fillable, Blank Medical Questionnaire For Accommodation Request For Pregnancy, Childbirth, And Related Conditions (City of Chicago) Form

Use Fill to complete blank online CITY OF CHICAGO (IL) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Medical Questionnaire For Accommodation Request For Pregnancy, Childbirth, And Related Conditions (City of Chicago)

On average this form takes 4 minutes to complete

The Medical Questionnaire For Accommodation Request For Pregnancy, Childbirth, And Related Conditions (City of Chicago) form is 2 pages long and contains:

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

Country of origin: US
File type: PDF

U.S.A. forms for City of Chicago

BROWSE CITY OF CHICAGO (IL) 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
 
Eff. Feb. 1, 2019 Page 1 of 2
MEDICAL QUESTIONNAIRE
For Accommodation Request for Pregnancy, Childbirth, and Related
Conditions
This form is to be completed by the medical provider of a City of Chicago employee, job applicant, or volunteer who is
seeking an accommodation for pregnancy, childbirth, or related conditions.
Please answer the questions below, providing as much detail as possible. Please fax the completed form to the 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 the Disability Officer at (312) 744 -4969.
YOUR PATIENT -- OUR EMPLOYEE/APPLICANT/VOLUNTEER
Name:
Email:
Cell Phone or Work Phone:
Home Mailing Address:
Department:
Job Title:
QUESTIONS TO DOCUMENT THE REASON FOR THE REQUEST
1. Is the employee/applicant/volunteer pregnant?
Yes No
2. Is the employee/applicant/volunteer recovering from childbirth?
Yes No
3. Please describe the reasonable accommodations or modifications which you believe are medically advisable based
upon the pregnancy, childbirth, or related common or medical condition of the employee/ applicant/volunteer.
4. Is the reasonable accommodation or modification necessary because of a common or medical condition related to
pregnancy or childbirth?
Yes No
5. Please explain why the accommodation is necessary:
Eff. Feb. 1, 2019 Page 2 of 2
MEDICAL QUESTIONNAIRE
For Accommodation Request for Pregnancy, Childbirth, and Related
Conditions
6. What is the date that the requested accommodation became or will become medically advisable ?
7. What is the probable duration of the need for accommodation?
By signing below, I attest that the information provided in this document is true and accurate to the best of my
knowledge. I understand that providing false or inaccurate information in this context is a crime punishable
under state and municipal law.
Medical Provider Name (print):
Date:
Medical Provider Signature:
Telephone:
Please attach a business card here:
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

Medical Questionnaire For Accommodation Request For Pregnancy, Childbirth, And Related Conditions (City of Chicago)

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 2 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document