ADA Reasonable Accommodation Request form

EMPLOYEE’S AUTHORIZATION RELEASE

For employee to complete:

I authorize (name of physician) ______________________________________________ or any other physicians involved in my care to release information to my employer regarding my physical (or mental) condition solely relating to my request for an accommodation under ADA. The information disclosed on this form shall only be used for the purpose of determining my ability to perform the essential functions of my job and whether or not the requested accommodation is reasonable.

_______________________________________

______________________

Employee’s Signature

Date

Internal Use Only Date Received: __________________

Received By: ___________________________________

Accommodation Requested is:  Approved  Denied  Modified

If modified describe modification and give rationale.

If denied, give rationale.

pg. 6

WSACTIVELLP:9187233.1

Made with FlippingBook - Online Brochure Maker