TL;DR This ADA Accommodation Request Form template is designed for healthcare providers to document and support workplace accommodation requests for patients with disabilities, detailing the patient's impairment, affected major life activities, and suggested accommodations. It emphasizes the necessity of customizing the form to comply with legal and regulatory standards, while also ensuring confidentiality and the patient's rights in the accommodation process.
Below is a template for an ADA (Americans with Disabilities Act) form that a doctor or healthcare provider might use in a workplace setting. This template provides a structure that can be adapted to specific needs and situations.
*Please note that this template should be reviewed and customized in accordance with the specific legal and regulatory requirements of your location and organization.
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[Your Medical Practice/Institution Name]
Patient Information:
Name: ___________________________________________________
Date of Birth: _____________________________________________
Address: __________________________________________________
Phone Number: ___________________________________________
Email Address: ____________________________________________
Employment Information:
Employer Name: ___________________________________________
Employer Address: _________________________________________
Job Title: _________________________________________________
Job Duties: ________________________________________________
Medical Information:
Treating Physician: ________________________________________
Contact Information of Treating Physician: _____________________
Questions to help determine whether an employee has a disability.
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 an impairment. The following questions may help determine whether an employee has a disability:Does the employee have a physical or mental impairment that meets this definition?
___ Yes ___ No
If yes, what major life activity(s) (includes major bodily functions) is/are affected?
Major Life Activities:
Bending - Breathing - Caring For Self - Concentrating - Eating - Hearing - Interacting With Others - Learning - Lifting - Performing Manual Tasks - Reaching - Reading - Seeing - Sitting - Sleeping - Speaking - Standing - Thinking - Walking - Working - Other: (describe)
Major bodily functions:
Bladder - Bowel - Brain - Cardiovascular - Circulatory - Digestive - Endocrine - Genitourinary - Hemic - Immune - Lymphatic - Muscular - Skeletal - Neurological - Normal Cell Growth - Operation of an Organ - Reproductive - Respiratory - Special Sense Organs & Skin - Other: (describe)
Necessity of an Accommodation:
What limitation(s) is interfering with job performance or accessing a benefit of employment?
What job function(s) or benefits of employment is the employee having trouble performing or accessing because of the limitation(s)?
How does the employee’s limitation(s) interfere with his/her ability to perform the job function(s) or access a benefit of employment?
Effective Workplace Accommodation Options:
Detail the specific accommodations recommended to assist the employee in performing their job duties. These may include, but are not limited to, changes in work schedule, modification of equipment, provision of assistive devices, or restructuring of job duties, as example.
Besides the above suggested accommodations, are there alternative accommodations that would provide the necessary support? If yes, please list and describe them here.Other comments:
Physician’s Declaration:
I, [Physician’s Name], certify that the information provided above is accurate to the best of my knowledge and that the recommended accommodations are necessary for the patients named above to perform their essential job functions due to their disability.
Physician’s Signature: ___________________________ Date: _______________
Patient Consent:
I, [Patient’s Name], consent to release this information to my employer to process my ADA accommodation request.
Patient’s Signature: ___________________________ Date: _______________
Please ensure that any ADA accommodation request form complies with local and federal laws and respects the confidentiality and rights of the patient. It's also recommended that you consult with legal counsel or an HR professional to ensure that the form meets all necessary legal standards and requirements.
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