If yes , what major bodily function(s) is/are affected?
Bladder Bowel Brain Cardiovascular Circulatory
Digestive Endocrine Genitourinary Hemic Immune
Lymphatic Musculoskeletal Neurological
Reproductive Respiratory Special Sense Organs & Skin Other: (describe)
Normal Cell Growth Operation of an Organ
2. Does the employee’s condition for which he/she has requested a workplace accommodation affect the employee’s ability to perform any one of the essential functions of the position, which are identified in the job description? Yes No If yes, please describe the impact on the person’s ability to perform specific functions.
3. Are there any accommodations that, in your opinion, would allow the employee to perform the essential functions of the job? Yes No If yes, please describe those accommodations, including frequency, duration, or time period of flare-ups; anticipated length of time that accommodation will be needed and anticipated frequency that accommodation will be needed; and frequency, number and schedule of anticipated follow-up treatment appointments.
4. If the employee cannot perform the essential functions of this position with or without an accommodation, what type of work, if any, can the employee perform with or without an accommodation? Please be specific.
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