Sample Medical Letter For Reasonable Accommodation
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If this form requires notarization, complete it online through a secure video call—no need to meet a notary in person or wait for an appointment.
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FAQ
[Example 1] As a result of [Name]'s disability, she occasionally experiences episodes of disorientation and dizziness. During these episodes, [Name] must sit or lie down for a few minutes to recover. Therefore, [Name] needs, as an accommodation, permission to take these short breaks.
Dear [Insert employer's name here]: I have been having medical issues that have affected my mood, sleep schedule, concentration, and focus. I would like to request accommodations so that I might be able to perform my job effectively before my performance starts to suffer.
I am writing to request permission to telework as a reasonable accommodation under the ADA. As you may know, I have a disability (you may list your disability here or wait for your employer to request documentation of your disability) and this accommodation would help me be successful at my job.
Content to consider in body of letter: Identify yourself as a person with a disability. State that you are requesting accommodations under the ADA (or the Rehabilitation Act of 1973 if you are a federal employee) Identify your specific problematic job tasks. Identify your accommodation ideas.
A brief statement of the doctor's credentials and history of treating the employee. The employee's diagnosis, including how the condition would manifest if left untreated. (This information is necessary to allow the employer to determine whether the employee has a disability under the ADA.)
