MEDICAL INFORMATION TO SUPPORT A

REASONABLE ACCOMMODATION REQUEST

TO BE COMPLETED BY A MEDICAL PROVIDER

All sections must be filled out thoroughly and be legible

The purpose of this document is to request information regarding your medical condition(s). This 

information is needed to determine whether, under applicable laws, you have a disability that 

requires a reasonable accommodation and, if so, what accommodations would enable you to 

perform the essential functions of your position and/or enjoy the benefits and privileges of your 

employment. This request is part of the interactive process mandated by the Equal Employment 

Opportunity Commission. To consider your request for a reasonable accommodation, an 

assessment of your welcome condition is required by a licensed medical physician. An acceptable 

diagnosis of your condition must include the information stated below.

Please give a copy of this document along with a copy of your position description to your medical 

provider, so they are aware of your current position.

Employee Name: _______________________________________________________________

Job Title: _____________________________________________________________________ 

Date: _________________________________________________________________________ 

1. Does this employee currently have a physical impairment?

___No

___Yes

Does this employee currently have a mental impairment? 

___No 

___Yes 

Describe the impairment(s) in detail, including diagnosis:
2. Does this impairment substantially limit a major life function? 

___No 

___Yes. Describe below in detail the limitation and impact on daily activity; to include past, 

present, and future nature, severity, and duration of the impairment. For example, 

functional limitations, symptoms, side effects of treatments;

3. What major life activity is substantially limited by the above impairment? 

___Caring for one’s self

___Performing manual tasks

___Walking 

___Seeing 

___Hearing 

___Speaking 

___Breathing 

___Learning 

___Lifting 

___Working

___Sitting 

___Standing 

___Reaching 

___Bending 

___Interacting with other people

___Communicating

___Concentrating

___Eating 

___Sleeping 

___Major bodily functions

___Reading 
___Other:

MEDICAL INFORMATION TO SUPPORT A REASONABLE ACCOMMODATION 

REQUEST, P. 2

4. The duration of the impairment is: 

___Temporary 

___Permanent

___Provide in detail how long the RA is needed:

5. Can the impairment be controlled or mitigated by medication or other medical intervention? 

___No 

___Yes. Describe any limitations in detail:

6. Employee should provide you a copy of their position description or a list of their essential 

functions. Is the employee able to perform the full duties/essential functions of the position? 

___Yes 

___No. Describe any limitations in detail:

7. An employee must be able to complete the essential functions of the job with or without a 

reasonable accommodation. If the employee is not able to perform the full duties of the 

position, please note any specific accommodation(s) that you believe would enable the 

employee to perform the full duties of the position and how the accommodation will assist 

the employee in performing the duties:
8. If an accommodation is granted, is there potential for injury to the employee or to others 

while performing the essential functions of the position? 

___No 

___Yes. Describe in detail the nature and likelihood of injury:

MEDICAL INFORMATION TO SUPPORT A REASONABLE ACCOMMODATION 

REQUEST, P. 3

9. Please state how the functional limitations affect the ability to perform the essential functions 

of the job and how the reasonable accommodation requested will enable the employee to 

perform those functions.

10. List any additional information you believe would be necessary or helpful in determining the 

employee’s need for accommodation.

________________________________ ______________ ________________________ 

Medical Provider’s Printed Name/Title Provider’s Stamp Medical Provider’s Signature

Date: _________________________________________________________________________

Address: ______________________________________________________________________

City/State/Zip code: _____________________________________________________________

Phone number: _________________________________________________________________