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SAMPLE MEDICAL INQUIRY FORM IN RESPONSE TO AN ACCOMMODATION REQUEST A. Questions to help determine whether an employee has a disability. A person has a disability under the ADA if the person has an impairment that substantially limits one or more major life activities. The following questions may help determine whether an employee has a disability Does the employee have a physical or mental impairment Yes No What is the impairment Is the impairment long-term or permanent If not permanent how long will the impairment likely last Does the impairment affect a major life activity If yes what major life activity s is/are affected Caring For Self Interacting With Others Performing Manual Tasks Breathing Working Walking Standing Reaching Thinking Toileting Hearing Seeing Speaking Learning Sitting Is the employee substantially limited in one or more of these major life activities Lifting Concentrating Reproduction Other describe An employee with a disability is entitled to an accommodation onl....

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A. The ADA provides that an employer cannot require a qualified individual with a disability to accept an accommodation that is neither requested nor needed by the individual. However, if a necessary reasonable accommodation is refused, the individual may be considered not qualified. Q.

What does the ADA require an employer to do? Employers covered by the ADA have to make sure that people with disabilities: have an equal opportunity to apply for jobs and to work in jobs for which they are qualified; ... have equal access to benefits and privileges of employment that are offered to other employees; and.

Title I of the Americans with Disabilities Act (ADA) requires employers to provide reasonable accommodation to qualified applicants and employees with a disability unless the employer can demonstrate that doing so creates an undue hardship to the employer or poses a direct threat to the safety of the employee or others ...

If you elect to request extended unpaid leave, leave may be granted to you if you qualify to receive an accommodation under the ADA, and if the accommodation will not pose an undue hardship. You may be asked to provide additional medical information to support the continuing need for leave.

A medical inquiry is any question about an individual's health or disabilities. ... Examples of medical inquiries: 1. Asking whether you have been treated for a specific condition or disease.

An employee who believes s/he has been wrongly denied a reasonable accommodation may: Request reconsideration by the agency. File a complaint with the agency EEO Counselor or ADA Coordinator. File a complaint with the DC Office of Disability Rights.

Keep it simple. You can tell your employer that you need an adjustment or change because of a medical condition. ... Put it in writing. ... Talk to the right people. ... How it works: an example. ... Finding help.

If you have a disability and are qualified to do a job, the ADA protects you from job discrimination on the basis of your disability. ... The ADA also protects you if you have a history of such a disability, or if an employer believes that you have such a disability, even if you don't.

According to the EEOC, you only have to let your employer know that you need an adjustment or change at work for a reason related to a medical condition. You can use "plain English" to make your request and you do not have to mention the ADA or use the phrase "reasonable accommodation."

To be protected by the ADA, one must have a disability, which is defined by the ADA as a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232