Medical Inquiry Form in Response to an Accommodation Request
This form is to be completed by a diagnosing Physician or Health/Mental Health Provider. Please answer the following questions to the best of your ability in order to assist Oakland University in evaluating an accommodation request. Oakland University will utilize this information to assess the employee's accommodation request, and the information you provide will remain confidential.
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Email *
Employee name:
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Job Title/Position:
Phone number:
Have you examined the employee for an impairment related to their request for a reasonable accommodation? If yes, please provide the dates of the examination.
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Does the employee have a physical or mental impairment? If yes, please describe the impairment.
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Does the impairment substantially limit a major life activity as compared to most people in the general population? If yes, what major life activities or major bodily functions are affected?
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What limitations interfere with job performance or access?
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Based on the limitations, what job functions does the employee have trouble performing or accessing?
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Do you have any suggestions for possible accommodations?
Are there any additional comments you would like to add?
Medical Provider Name:
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License #:
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Office Telephone Number:
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Address:
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State:
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Zip Code:
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Date:
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