Fill and Sign the Request for Medical Status Evaluation under Ada Form

REQUEST FOR MEDICAL STATUS EVALUATION UNDER ADA In order to make a determination about the nature of this employee’s medical condition, and whether the employee might be considered a qualified individual with a disability under the Americans with Disabilities Act (ADA), the Company requests the following information from the individual’s healthcare practitioner. This information is treated confidentially, is not maintained in the employee's main personnel file, and will be used only by authorized individuals with direct need to know and/or evaluate the information. Please return this form to: Leave/Disability CoordinatorHR Benefits Office Phone: _________ Fax: _________ THIS SECTION TO BE COMPLETED BY EMPLOYEE:Employee's Name: Soc Sec #: Date of Birth: Street Address, City, State, ZIP: Day Phone: 1Eve Phone: 111In order for the company to evaluate my status with regard to possible need for accommodation, my healthcare provider may release this information and may provide additional clarification/information/documentation if requested by the company.Employee Signature:_____________________________THIS SECTION TO BE COMPLETED & FORWARDED BY HEALTH CARE PROVIDER:Name of Physician/Practitioner: Degree/Specialty/Type of Practice: Street Address, City, State, ZIP: Office Phone: 1. Please state the patient's diagnosis and briefly describe the medical facts that support your certification. a)When did symptoms first appear? b) Subjective symptoms: 2. In your professional judgment, does this individual have a physical impairment that "is a physiological disorder, or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: a) neurological g) digestive b) musculoskeletal h) genito-urinary c) special sense organs i ) hemic and lymphaticd) respiratory (including speech organs)j ) skin Yes No e) cardiovascular k) endocrinef) reproductive If yes, please explain in detail below. 3. In your professional judgment, does the individual have a mental impairment that meets the following definition: "Any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities." Yes No If yes, please explain in detail. 4.Under ADA regulations, major life activities are described as activities that an average person can perform with little or no difficulty. The regulations do not offer an exhaustive list but mention the following examples: sitting breathing      seeing caring for oneself walking   performing manual tasks   learning    In your professional judgment, does this individual have an impairment that limits one or more major life activities according to this definition? Yes No If yes, please describe in detail. 5.The limitation to major life activities must be substantial under the regulations: "An individual must be unable to perform, or be significantly limited in the ability to perform, the function.1 " There are three factors to consider in determining whether a person's impairment substantially limits a major life activity: a)The nature and severity of the impairmentb)How long the impairment will last or is expected to lastc)The permanent or long-term impact or expected impactIn your professional judgment, is the individual's impairment substantial? Yes NoIf yes, explain how the above factors individually or in combination substantially limit the individual in the performance of one or more major life activities. 6.a) If you believe the individual to have a disability that substantially limits the individual's ability to perform one or more major life functions, in your professional opinion, can the individual perform the essential functions of the job (based on the job description), with or without an accommodation, and without direct threat to their own health and safety and/or the health and safety of others in the workplace? Yes Nob) Is an accommodation required to enable the individual to perform the essential functions of the job as described? Yes No c) If accommodation is required, can you suggest or recommend one or more possible reasonable accommodations that would specifically and directly address/ameliorate the substantial limitation and enable the individual to successfully perform the essential functions of the job? Yes NoIf yes, please suggest reasonable accommodation(s), and describe how such accommodation would enable the individual to successfully perform the essential functions of the job: 7. a) In your professional judgment, can the individual’s medical condition be successfully ameliorated with treatment (e.g., medication, diet, physical therapy, surgical treatment)? Yes No b) If yes to 7a, is the individual compliant with your recommended course of treatment? Yes No If no, please explain in detail: 8.a) Regular attendance is an essential function of virtually all jobs, and an individual who cannot attend work regularly therefore may not qualify as "able to perform the essential functions of the position." In your professional judgment, does this medical condition create impairment that might ordinarily cause the individual to be unable to report to work in any substantive way? Yes No b) If yes to 8a, what is the general expectation of the average number of days this individual might be expected to miss work: _______ work days/month (month = 22 work days)_______ work days per year (year = 262 work days) 9.Please provide any further information you feel would be useful to the company in evaluating the individual's medical condition. ___________________________________________ Date: _______ SIGNATURE(please do not use signature stamp or designee signature)