ADA Reasonable Accommodation Request form

MAA AMERICANS WITH DISABILITIES ACT (ADA) REASONABLE ACCOMMODATION REQUEST Health Care Provider Documentation in Support of the Request

Date:________________________________

Employee’s Name: ___________________________________

Position Held:_______________________________________

________________________________ , who is an employee of MAA, has requested a reasonable accommodation under the Americans with Disabilities ADA (ADA). Attached to this form is the current job description of the essential functions of the position, including the physical and mental demands of the job. Please answer the following questions regarding the employee’s condition solely as it relates to the essential functions and possible accommodations. ** The employee’s signed Release is also attached. 1. Solely with respect to the impairment for which the employee has requested a workplace accommodation, does the employee’s condition constitute a disability that substantially limits a major life activity?  Yes  No NOTE: An impairment is a disability if it substantially limits the ability of an individual to perform a major life activity as compared to most people in the general population. “Substantially limits” is to be determined broadly. An impairment need not prevent or significantly or severely restrict the individual’s ability to perform a major life activity. Impairments lasting fewer than six (6) months can be substantially limiting. An impairment that is episodic or in remission is a disability if it would substantially limit a major life activity when active.

If yes , what major life activity(s) is/are affected?

 Bending  Breathing

 Hearing  Interacting With Others  Learning  Lifting  Performing Manual Tasks

 Reaching  Reading  Seeing  Sitting  Sleeping

 Speaking  Standing  Thinking  Walking  Working

 Other: (describe)

 Caring For Self  Concentrating  Eating

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