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SAMPLE MEDICAL INQUIRY FORM IN RESPONSE TO AN ACCOMMODATION REQUEST A. Questions to help determine whether an employee has a disability. A person has a disability under the ADA if the person has an impairment that substantially limits one or more major life activities. The following questions may help determine whether an employee has a disability Does the employee have a physical or mental impairment Yes No What is the impairment Is the impairment long-term or permanent If not permanent how long will the impairment likely last Does the impairment affect a major life activity If yes what major life activity s is/are affected Caring For Self Interacting With Others Performing Manual Tasks Breathing Working Walking Standing Reaching Thinking Toileting Hearing Seeing Speaking Learning Sitting Is the employee substantially limited in one or more of these major life activities Lifting Concentrating Reproduction Other describe An employee with a disability is entitled to an accommodation only when the accommodation is needed because of the disability. The following questions may help determine whether the requested accommodation is needed because of the disability What limitation s is interfering with job performance What job function s is the employee having trouble performing because of the limitation s How does the employee s limitation s interfere with his/her ability to perform the job function s Page 2 of 2 If an employee has a disability and needs an accommodation because of the disability the employer must provide a reasonable accommodation unless the accommodation poses an undue hardship* The following questions may help determine effective accommodations Do you have any suggestions regarding possible accommodations to improve job performance If so what are they How would your suggestions improve the employee s job performance D. A person has a disability under the ADA if the person has an impairment that substantially limits one or more major life activities. The following questions may help determine whether an employee has a disability Does the employee have a physical or mental impairment Yes No What is the impairment Is the impairment long-term or permanent If not permanent how long will the impairment likely last Does the impairment affect a major life activity If yes what major life activity s is/are affected Caring For Self Interacting With Others Performing Manual Tasks Breathing Working Walking Standing Reaching Thinking Toileting Hearing Seeing Speaking Learning Sitting Is the employee substantially limited in one or more of these major life activities Lifting Concentrating Reproduction Other describe An employee with a disability is entitled to an accommodation only when the accommodation is needed because of the disability. The following questions may help determine whether an employee has a disability Does the employee have a physical or mental impairment Yes No What is the impairment Is the impairment long-term or permanent If not permanent how long will the impairment likely last Does the impairment affect a major life activity If yes what major life activity s is/are affected Caring For Self Interacting With Others Performing Manual Tasks Breathing Working Walking Standing Reaching Thinking Toileting Hearing Seeing Speaking Learning Sitting Is the employee substantially limited in one or more of these major life activities Lifting Concentrating Reproduction Other describe An employee with a disability is entitled to an accommodation only when the accommodation is needed because of the disability. The following questions may help determine whether the requested accommodation is needed because of the disability What limitation s is interfering with job performance What job function s is the employee having trouble performing because of the limitation s How does the employee s limitation s interfere with his/her ability to perform the job function s Page 2 of 2 If an employee has a disability and needs an accommodation because of the disability the employer must provide a reasonable accommodation unless the accommodation poses an undue hardship* The following questions may help determine effective accommodations Do you have any suggestions regarding possible accommodations to improve job performance If so what are they How would your suggestions improve the employee s job performance D.