Dear Medical Professional:

An individual under your care has requested a reasonable accommodation from their employer. In order to assist with the process, we 

are requesting you to provide feedback to the following questions based on your medical expertise. Under the ADAAA, an employee has 

a disability if he/she has an impairment that “substantially limits” one or more major life activities. Additionally, the definition has been 

broadened to include someone with an impairment who is “regarded as” having a disability, provided that the impairment does not have 

an actual or expected duration less than or equal to 6 months. 

When answering the questions below, please consider the above named individual when their condition is at its worst and without any 

accommodations in place.

Please return this form to the employee or directly to the Agency within 15 days of receipt.

PART I—REQUESTER’S CONTACT INFORMATION

Requester’s Name: Date of Accommodation Request: Date of Medical Documentation Request:

PART II—DISABILITY INFORMATION

1. Given the ADAAA definition above, does the above named individual have a disability?

Yes No

If yes, please provide detailed diagnosis/diagnoses (include ICD/DSM-V code):

2. What “major life activities” are impacted by this disability?

Caring for oneself

Seeing

Eating

Walking

Lifting

Breathing

Reading

Thinking

Working

Other

Other

Performing manual tasks

Hearing 

Sleeping

Standing

Bending

Learning

Concentrating

Communicating

Operation of a major bodily function

Other

Other

3. What is the expected duration of the above impact to the employee’s major life activities?

Less than 6 months Greater than 6 months (but not permanent) Permanent

4. What specific work restrictions or accommodations, if any, do you recommend?

5. If you are recommending restrictions or accommodations, please provide the duration.

6. How will the above restrictions/accommodations enable the individual to perform the essential functions or enjoy employment

benefits of their job?

7. Comments/additional considerations:

Health Care Provider’s Address: Health Care Provider’s Printed Name:

Health Care Provider’s Signature:

PLEASE RETURN FORM TO:

DIA 7400 Pentagon

Attn: EO/Reasonable Accommodation

Washington, DC 20301

reasonableaccommodations@dodiis.mil

Phone: (202) 231-8178

Fax: (202) 231-6486

Authority: Federal Rehabilitation Act of 1973, as amended, Rehabilitation Act–29 CFR 1614.203, as amended, Americans with Disabilities Act, as amended, Executive Order 13164,

“Establishing Procedures to Facilitate the Provision of Reasonable Accommodation,” as amended, DoD Directive 1020.02, “Diversity Management and Equal Opportunity in the

Department of Defense,” as amended, DIA Directive (DIAD) 1020.100, “DIA Equal Employment Opportunity and Diversity Program,” 15 May 2014.

Purpose: To evaluate information in response to a Reasonable Accommodation Request.

Routine Uses: Routine uses of the information are consistent with the Defense Reasonable Accommodations and Assistive Technology Records, System of Records Notice DoD 0007. 

Additional information is available at https://www.federalregister.gov/documents/2021/07/22/2021-15601/privacy-act-of-1974-system-of-records

Disclosure of Information: Providing this information is voluntary; however, failure to complete the form in its entirety could result in a denial or delay of the requested service.

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Request for Physician Certification of Accommodation Request

DIA 1020.1