DTRA REASONABLE ACCOMMODATION REQUEST 

MEDICAL INQUIRY FORM

CUI

ATTENTION

Use this space to indicate categories, limited dissemination controls, special

instructions, points of contact, etc. if needed.

ATTENTION

All individuals handling this information are required to protect

it from unauthorized disclosure.

Handling, storage, reproduction, and disposition of the attached document(s) must

be in accordance with 32 CFR Part 2002 and applicable agency policy.

Access to and dissemination of Controlled Unclassified Information shall be

allowed as necessary and permissible to any individual(s), organization(s), or

grouping(s) of users, provided such access or dissemination is consistent with or in

furtherance of a Lawful Government Purpose and in a manner consistent with

applicable law, regulations, and Government-wide policies.

CUI

Controlled by:

CUI Categor(ies):

LDC or Distribution Statement:

POC:

DTRA Form 259 (JUNE 2022) (Adobe LiveCycle ES)
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTRA REASONABLE ACCOMMODATION REQUEST 

MEDICAL INQUIRY FORM

6. IS THE IMPAIRMENT LONG-TERM OR PERMANENT?

9. Does the impairment substantially limit the operation of a major bodily function?

Note: Does not need to significantly or severely restrict to meet this standard.

Privacy Act Statement

Authority: Rehabilitation Act of 1973 (Section 501 and 505); 29 Code of Federal Regulations (CFR) Part 1630; E.O 13163; E.O. 13164, EEOC Policy; and

DTRA 5505.3, DTRA Reasonable Accommodation Instruction.

Purpose(s): To provide reasonable accommodation(s) for individuals with known physical and mental impairments who have applied for employment or are

employees of the DTRA.

Routine uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, information contained therein may specifically be

disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: The DOD `Blanket Routine Uses' apply. The DoD Health Information

Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and Accountability Act of 1996, alos applies to most such health

information.

Disclosure: Voluntary; however, failure to provide this information may delay or impede your Reasonable Accommodation Request.

A. QUESTION TO DETERMINE WHETHER AN EMPLOYEE HAS A DISABILITY.

5. DOES THE EMPLOYEE HAV E A PHYSICAL OR MENTAL IMPAIRMENT?

Yes No

6a. IF NOT PERMANENT, HOW LONG WILL THE IMPAIRMENT LIKELY LAST?

5a. IF YES, WHAT KIND OF IMPAIRMENT?

Yes No

7. Does the impairment substantially limit a major life activity?

Note: Does not need to significantly or severely restrict to meet this standard

Yes No

Yes No

7a. If yes, what major life activity(s) is/are affected?

Answer the following questions based on what limitations the employee has when his or her condition is in an active state and what limitations the employee

would have if no mitigating measures were used. Mitigating measures include things such as medication, medical supplies, equipment, hearing aids, mobility

devices, the use of assistive technology, reasonable accommodations or auxiliary aids or services, prosthetics, and learned behavioral or adaptive neurological

modifications. Mitigating measures do not include ordinary eyeglasses or contact lenses.

For reasonable accommodation under the ADA, an employee has a disability if he or she has an impairment that substantially limits one or more major life

activities or a record of such impairment. The following questions will determine whether an employee has a disability:

1. NAME (Last, First, MI): 2. TELEPHONE NUMBER:

3. DIRECTORATE/ STAFF OFFICE: 4. SUPERVISOR:

8. PLEASE PROVIDE AND EXPLANATION (I.E. 100LBS)

Caring For Self

Toileting

Hearing

Other: (describe)

Reproduction

Concentrating

Sleeping

Lifting

Seeing

Speaking

Learning

Sitting

Thinking

Reaching

Standing

Walking

Breathing

Working

Performing Manual Tasks

Interacting With Others

DTRA Form 259 (JUNE 2022) (Adobe LiveCycle ES)
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTRA REASONABLE ACCOMMODATION REQUEST 

MEDICAL INQUIRY FORM

A. QUESTION TO DETERMINE WHETHER AN EMPLOYEE HAS A DISABILITY (CONTINUED).

9a. If yes, what bodily function is affected?

Immune

Brain

Circulatory Other: (describe)

Genitourinary Respiratory Cardiovascular

Endocrine

Reproductive

Musculoskeletal

Special Sense

Neurological

Lymphatic

Special Sense Organs and Skin

Hemic

Bowel

Bladder

Digestive

Normal Cell Growth

An employee with a disability is entitled to an accommodation only when the accommodation is needed because of the disability. The following questions may

help determine whether the requested accommodation is needed because of the disability:

B. QUESTIONS TO HELP DETERMINE WHETHER AN ACCOMMODATION IS NEEDED.

10. WHAT LIMITATION(S) IS INTERFERING WITH JOB PERFORMANCE?

11. WHAT JOB FUNCTION(S) IS THE EMPLOYEE HAVING TROUBLE PERFORMING BECAUSE OF THE LIMITATION(S)?

12. HOW DOES THE EMPLOYEE'S LIMITATION(S) INTERFERE WITH HIS/HER ABILITY TO PERFORM THE JOB FUNCTION(S)?

If an employee has a disability and needs an accommodation because of the disability, the employer must provide a reasonable accommodation, unless the

accommodation poses an undue hardship.

C. EFFECTIVE ACCOMMODATION OPTIONS.

13a. IF SO, WHAT ARE THE

D. ADDITIONAL COMMENTS:

Please insure this form is provided to the Human Resources Office, Reasonable 

Accommodation Coordinator after it has been signed by a Health Care Provider 

14. MEDICAL PROFESSIONAL SIGNATURE 15. DATE

13. BASED ON YOUR REVIEW DO YOU HAVE ANY RECOMMENDATIONS REGARDING THE REQUESTED ACCOMMODATION? Yes No

DTRA Form 259 (JUNE 2022) (Adobe LiveCycle ES)