LAC 22:I.205. Medical Inquiry Form

MEDICAL INQUIRY FORM RESPONSIVE TO ACCOMMODATION REQUEST FOR COMPLETION BY EMPLOYEE Employee’s Name: _______________________________________ Authorization for Release of Medical Information I authorize my Healthcare Provider to release medical information that is specifically related to and necessary for my employer to determine whether I have a disability for which an accommodation(s) may be needed. I authorize my Healthcare Provider to speak directly to my Agency ADA Coordinator in regards to my medical condition and its effects upon my ability to perform the essential functions of my job. I understand that I may refuse to sign this Authorization. However, I understand that my failure to permit these disclosures may impact my employer’s ability to fully address my request for accommodation. Employee’s Signature: _____________________________________________ Date: _______________ FOR COMPLETION BY HEALTHCARE PROVIDER SECTION 1: Questions to determine whether employee has a disability For reasonable accommodation under the Americans with Disabilities Act (ADA), an employee has a disability if he/she has an impairment that substantially limits one or more major life activities or has a record of such an impairment. The following information may help to determine whether an employee has a disability: Does the employee have a physical or mental impairment? Yes (proceed to section A. below) No (discontinue completion of form) A. What is the impairment or the nature of the impairment? ___________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ B. Does the impairment substantially limit a major life activity as compared to the general population? Yes No C. What major life activity(s) and/or major bodily function(s) is limited? Major Life Activities: Bending | Eating | Lifting | Seeing | Standing Breathing | Hearing | Performing Manual Tasks | Sitting | Thinking Caring for Self | Interacting with Others | Reaching | Sleeping | Walking Concentrating | Learning | Reading | Speaking | Working Other: Major Bodily Functions: Bladder | Circulatory | Hemic | Neurological | Respiratory Bowel | Digestive | Immune | Normal Cell Growth | Special Sense Organs & Skin Brain | Endocrine | Lymphatic | Operation of an Organ | Special Sense Organs & Skin Cardiovascular | Genitourinary | Musculoskeletal | Reproductive | Special Sense Organs & Skin Other: D. Describe any functional limitations caused by the impairment: _______________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ SECTION 2: Questions to help determine whether an accommodation is needed. An employee with a disability is entitled to an accommodation only when the accommodation is needed because of the disability. The following information may help determine whether the requested accommodation is needed because of the disability: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Health Care Provider’s Signature: _______________________________________ Date: __________ Health Care Provider’s Name (Printed): _____________________________________ Practice Specialty: ______________________________________________________ Clinic Name: ___________________________________________________________ Address: ______________________________________________________________________________________ Telephone #: ____________________________________ Fax #: __________________________________ RETURN COMPLETED FORM DIRECTLY TO [INSERT NAME], AGENCY ADA COORDINATOR By Fax to: (225) 342-XXXX; or, email to: firstname.lastname@la.gov