Download Employee Request for ADA Accommodation

EMPLOYEE REQUEST FOR ADA
ACCOMMODATION
PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS FORM:
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered
by GINA Title II from requesting or requiring genetic information of an individual or family member of the
individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide
any genetic information when responding to this request for medical information. “Genetic information,” as
defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s
genetic tests, the fact that an individual or an individual’s family member sought or received genetic services,
and genetic information of a fetus carried by an individual or an individual’s family member or an embryo
lawfully held by an individual or family member receiving assistive reproductive services.
Employee Name
Date
Work Schedule (Days and Hours)
1.
Please use back of sheet if you need more room to answer any questions listed below.
Please describe the physical, mental, or cognitive impairment(s) that limit your ability to do your job.
2.
Describe the accommodations you are requesting. Be as specific as possible (i.e. if you are requesting a piece
of equipment or device, please provide description, manufacturer, cost, where to order, etc.)
3.
Describe how the requested accommodations will enable you to perform your job.
4.
Please provide any other information that might help West Liberty University evaluate your request.
I give West Liberty University permission to explore coverage and reasonable accommodations under the
Americans with Disabilities Act. This may include speaking to my health care professional. I understand that all
information obtained during this process will be maintained and used in accordance with ADA confidentiality
requirements. I further understand that I will be required to provide appropriate documentation of my disability,
including the impact of the functional limitations on my ability to perform the essential functions of my job, and
my failure to submit such information may result in the denial of my request.
Signature
Cc: File
Date
ADA MEDICAL
CERTIFICATION FORM
PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS FORM:
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered
by GINA Title II from requesting or requiring genetic information of an individual or family member of the
individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide
any genetic information when responding to this request for medical information. “Genetic information,” as
defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s
genetic tests, the fact that an individual or an individual’s family member sought or received genetic services,
and genetic information of a fetus carried by an individual or an individual’s family member or an embryo
lawfully held by an individual or family member receiving assistive reproductive services.
The information sought on this form pertains only to the condition for which the employee is requesting
accommodation under the ADA.
To be completed by
HEALTH CARE PROVIDER
To be completed by
EMPLOYEE
NOTE TO EMPLOYEES/PROVIDERS IN CALIFORNIA: In California, the Health Care Provider completing this form
may not disclose the underlying diagnosis without the Employee/Patient's consent.
Employee Name
Job Title:
Employee Signature:
Date:
INSTRUCTIONS: Your patient has requested an accommodation in the workplace pursuant to the
Americans With Disabilities Act (ADA). We need more information in order to determine if and how
TeleTech can accommodate his or her request. Specifically, we need specific information about the
functional limitations of your patient's medical condition and his or her need for reasonable
accommodation.
Attached is a copy employee’s job description which identifies the essential functions of the position and
includes the physical/mental demands and environmental conditions associated with the job. Please
review the attached job description and then complete and sign this form. If you require any
assistance or information, please contact Human Resources.
Physician Name (Please Print):
Specialization/Type of Practice:
Address:
Cc: File
Department:
Phone #
To be completed by
HEALTH CARE PROVIDER
Questions to help determine whether an employee has a qualifying disability. A person has a qualifying
disability under the ADA if the person has an impairment that substantially limits one or more major life
activities.
1. Does the employee have a physical or mental impairment?
2. Is the impairment long-term or permanent?
3. If not permanent, how long will the impairment likely last?
4. Does the impairment mean that the employee is substantially limited
in one or more major life activities?
Yes
Yes
No
No
Yes
No
5. If yes, what major life activity(s) is/are affected:
caring for self
walking
hearing
lifting
interacting with others
standing
seeing
sleeping
performing manual tasks
reaching
speaking
concentrating
breathing
thinking
learning
working
toileting
sitting
reproduction
operation of a major bodily function: ______________________________________
To be completed by the
HEALTH CARE PROVIDER
Questions to help determine whether an accommodation is needed.
How does the employee’s limitation(s) in major life activities interfere with his/her ability to perform the
job functions listed in the attached job description?
Questions to help determine effective accommodation options.
1. Do you have any suggestions regarding possible accommodations to improve job performance? If so,
what are they?
2. How would your suggestion(s) improve the employee’s performance?
Comments:
SIGNATURE OF HEALTHCARE PROVIDER:______________________________________ Date: _______
***ALL INFORMATION PROVIDED IS CONFIDENTIAL AND WILL BE RETAINED IN THE EMPLOYEE’S MEDICAL FILE***
Cc: File
Cc: File