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Get Hartford Ada Medical Assessment 2017-2024

Returned no later than: Employee s Name: Last 4 digits of Social Security Number: Leave ID: Date of Birth: Employer s Name: Today s Date: The above employee has requested under the Americans with Disabilities Act Amendments Act (ADAAA), as amended, to enable the employee to perform the essential functions of his/her position. The information requested on this form will assist in making a determination regarding the employee s request. INSTRUCTIONS: The following form must be comple.

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