Fill and Sign the Ada Questionnaire for Physician Form

{ Insert Date } Insert Name Insert Address Insert City, State, and Zip Code Dear Dr. _______ : I am the { Insert Position Title } for { Insert Company Name }. { Insert Employee Name }, a patient of yours, is employed as a { Insert Employee's Position Title }. I am writing, with { Insert Employee Name } consent, to request your input regarding her employment. On (provide date and state the basis upon which you believe that employee’s performance related problems are associated with a potential disability ). This situation has raised concerns regarding { Insert Employee Name } ability to perform his/her job and whether he/she can do so in a safe manner. { Insert Employee Name } has told us that she is under your care and we therefore seek your assistance. Specifically, { Insert Company Name } would like your input to verify whether { Insert Employee Name } suffers from a disability under the Americans With Disabilities Act ("ADA"), and if one exists, the need for reasonable accommodation. In accordance with the ADA, { Insert Company Name } reasonably accommodates the limitations of disabled employees who request accommodation. Currently, we have insufficient information to determine whether { Insert Employee Name }is disabled under the ADA; namely, whether { Insert Employee Name } has a physical or mental impairment that substantially limits a major life activity. Attached is a questionnaire that will assist us in making this determination. We present this questionnaire merely as a device to solicit your input. Please do not feel bound by the questions we have asked or the manner in which they are presented. We are more than willing to discuss this matter with you directly, which may become necessary. However, we believe that the questionnaire will facilitate the process in determining the appropriate course of action. As stated in the questionnaire, if you determine that { Insert Employee Name } is disabled, please provide us with information regarding whether { Insert Employee Name } is in need of an accommodation to perform the essential functions of his/her job. Enclosed for your consideration is a copy of { Insert Employee Name } job description. Should you feel that any accommodation is necessary, please provide specifics. If you require more information regarding { Insert Employee Name } job duties, recent incidents, or other information regarding this request, please contact me. { Insert Employee Name } has signed the release below, which allows you to provide the requested information. Please send your response to my attention, in an envelope marked personal and confidential. Thank you for your cooperation. Should you have any questions, please call me. Sincerely yours, _________________________________ (Signature) Release of Medical Information You are hereby authorized to disclose and deliver to { Name of Company Official }, in her capacity as { Position Title }, or her authorized designee, any and all medical records, documents or information that would adequately respond to the above-request. Please respond to the above request promptly upon receipt of this authorization. Dated: __________ Employee Name: ______________________________ ADA Questionnaire Introduction To be disabled under the ADA,{ Insert Employee Name }must suffer from a physical or mental impairment that substantially limits a major life activity. Under the ADA regulations, a physical or mental impairment means (1) any physiological disorder, or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological, musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genito-unirnary, hemic and lymphatic, skin and endocrine; or (2) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. Major life activities include, but are not necessarily limited to, functions such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, thinking and working. As stated, to rise to the level of a disability, an impairment must substantially limit one or more major life activity of the individual. The ADA does not define substantially limits, but it has been decided that substantially suggests considerable or specified to a large degree. Whether the limitation rises to that level, you should assess: (i) the nature and severity of the impairment; (ii) the duration or expected duration of the impairment; and (iii) the permanent or long term impact, or the expected permanent or long term impact of or resulting from the impairment. Of course, substantial is a relative term and, therefore, (Employee name) may be substantially limited if you determine that she is (i) unable to perform a major life activity that the average person in the general population can perform; or (ii) significantly restricted as to the condition, manner or duration under which she can perform a particular major life activity as compared to the condition, manner, or duration under which the average person in the general population can perform that same major life activity. Please note, however, that in determining whether the condition substantially limits a major life activity you should evaluate the limitations in a treated state. That is, you should assess the effects, both positive and negative, of any mitigating measures (like medication) that can be used to lessen a limitation. By way of example, a near-sighted pilot whose vision is normal when wearing corrective lenses is not disabled under the ADA. If { Insert Employee Name } does not suffer from a physical or mental impairment that substantially limits a major life activity, she is not disabled under the ADA. Conversely, if she does suffer from such an impairment, she is disabled. However, as set forth in our letter to you, our interest is much more limited than determining whether { Insert Employee Name } is or is not disabled under the ADA. Notwithstanding the recent incidents involving { Insert Employee Name } she may suffer from a disability that is unrelated to the episodes or that has no impact on her ability to do her job at { Insert Company Name }. We are not interested in learning about any such disability. We are interested in knowing whether { Insert Employee Name }has any impairment-produced limitation that led to the recent episodes or is otherwise the cause of her poor job performance. In sum, if { Insert Employee Name } current job difficulties are a result of an ADA disability, we must know that in order to determine how to proceed. [Add if legitimate safety issue is present] Finally, given { Insert Employee Name }position as a [position] and the nature of the recent episodes, we are interested in determining whether she can perform her job without posing a direct threat to her own health and safety, and/or the health and safety of those with whom she works. We are not interested in remote or speculative risks; rather, we would like to know whether you believe that { Insert Employee Name }poses an identifiable, current specific risk that poses a significant threat of substantial harm to herself or others. Obviously, you should base your determination on objective medical or other factual evidence regarding { Insert Employee Name }. Disability Questions 1. Are the recent episodes the result of a physical or mental impairment? Yes or No (If no, you need not answer any other questions) 2. If you answered Yes to question 1, please specifically identify the nature of the impairment:                         3. Does the impairment substantially limit any major life activity? Yes or No (If no, you need not answer any other questions) 4. If you answered yes to question 3, please list the life activities that the impairment substantially limits?                         5. Describe how the impairment substantially limits each of the above listed life activities:                         6. What is the duration or expected duration of the impairment on each life activity?                         7. What is the permanent or long term impact, or the expected permanent or long term impact of or resulting from the impairment?                         8. Do you have any suggestions regarding how we may accommodate any of the limitations so that { Insert Employee Name } can perform her essential job functions?                         Safety Questions 1. Can you identify a current specific risk as a result of { Insert Name of Employee }disability that poses a significant threat of substantial harm to { Insert Name of Employee } or others. Yes or No (If no, you need not answer any other question) 2. Please describe the nature of the risk?                         3. Please describe the threat of harm?                         4. Please discuss whether and how an accommodation can eliminate or reduce the risk or threat?                         Physician’s Signature __________________________________________________________ Date:       Practice Area:       Street Address:       Phone Number: