HR ADA Questionnaire

HR ADA Questionnaire

Personal Information

Employee Name:

Employee ID:     Date of Birth:

Position Information

Supervisor / Manager:     Date Hired (or start date):

Employment Status: Full-time Part-time Temporary/Other

Employment History (Most recent two employers)

Dates Employed: From to

Dates Employed: From to

Education

References (Professional)

Disability / Medical Information (Confidential)

Do you have a medical condition, impairment, or disability that affects your ability to perform your job duties? Yes No

Date condition began or date of onset:     Expected duration:

Which major life activities are substantially limited by the condition? (check all that apply)

Hearing Seeing Walking Standing Lifting Bending

Speaking Communicating Concentration / Memory Other (explain below)

Work Limitations and Accommodation Request

Can you perform the essential functions of your job with the requested accommodation? Yes No Unknown / Needs assessment

Yes No

Medical Provider / Supporting Documentation

May the employer contact your health care provider to clarify the functional limitations and need for accommodation? Yes No

Interactive Process / Employer Review

I understand that submission of this form initiates the interactive process between employee and employer. The employer may request reasonable documentation from a health care provider to evaluate the need for and effectiveness of requested accommodations. The employer will maintain medical information as confidential and separate from personnel files to the extent required by law.

I authorize the release of medical information necessary to evaluate my request for reasonable accommodation and to monitor the effectiveness of any accommodation provided. I understand that refusal to provide necessary information may limit the employer's ability to provide an accommodation.

I authorize the employer to contact former employers and references to verify employment history as needed in connection with my accommodation request and any related personnel actions.

Legal Notices and Certifications

At-Will Employment: Nothing in this form alters the at-will employment relationship. Either the employee or the employer may terminate employment at any time, with or without cause or notice, unless otherwise provided by a separate written agreement signed by an authorized representative of the employer.

Equal Employment Opportunity: The employer prohibits discrimination and harassment and affords equal opportunity in all aspects of employment, including requests for reasonable accommodation, in accordance with applicable law.

Applicant / Employee Certification: I certify that all information provided on this form is true, accurate, and complete to the best of my knowledge. I understand that intentionally providing false information may subject me to disciplinary action, up to and including termination of employment. I further certify that I have read and understand the statements above regarding authorization to release medical information, the interactive process, and the employer's rights and responsibilities.

Authorization to Contact Previous Employers and Conduct Background Checks: By signing below I authorize the employer to contact my previous employers and references identified herein and to conduct any background checks necessary to verify information relevant to my employment and accommodation request, in compliance with applicable law.

Consent to Release Medical Records (Optional as needed)

I authorize my health care provider to release to the employer the medical information necessary to evaluate and implement reasonable accommodation(s). I understand that this authorization is limited to information necessary for the accommodation request and does not authorize release of unrelated medical records.

Signature below constitutes consent to release such information for the limited purpose stated and remains in effect for the duration reasonably necessary to review and implement the requested accommodation, unless earlier revoked in writing.

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