Americans with Disabilities Act (ADA)

Medical Professional’s Documentation of Disability

As part of the accommodation process, documentation that an employee has a qualifying disability is required. The ADA defines a qualifying disability as one that fits into one of these categories:

A physical or mental impairment that substantially limits one or more major life activities; or

A record of impairment; or

Regarded as having an impairment.

This form is designed to provide a method for compliance with this mandate for documentation and should be completed by the employee’s diagnosing professional.

Section I – Employee Information

Employee Name:	Employee PeopleSoft #:	Date:
Supervisor Name:	Work Phone:
Department:	Supervisor Work Phone:
Medical Professional Name:	Professional’s Title:
Professional’s Work Phone:	Professional’s license #:

Using the space below or by attaching a letter, please describe the diagnosis and how it fits into one of the categories above.
Please suggest accommodations relating to the above diagnoses (if any).

Section II – Medical Professional’s Evaluation

I certify that the employee has a physical, mental, emotional, impairment that limits one or more major life activity. The life function affected is: (circle all that apply) Caring for oneself, performing manual tasks, walking, seeing, hearing, sitting, speaking, breathing, learning, working, remembering, reasoning, other (please describe) Indicate the limitations of the employee below:
Physical Activity Limitation(s)
Sitting	Mild Moderate Severe	Repetitive use of Hands	Mild Moderate Severe
Standing	Mild Moderate Severe	Right only Left only Both	Mild Moderate Severe
Walking	Mild Moderate Severe	Mild Moderate Severe
Bending Over	Mild Moderate Severe	Mild Moderate Severe
Climbing	Mild Moderate Severe	Simple/Light Grasping	Mild Moderate Severe
Reaching Overhead	Mild Moderate Severe	Right only Left only Both	Mild Moderate Severe
Kneeling	Mild Moderate Severe	Mild Moderate Severe
Pushing and Pulling	Mild Moderate Severe	Mild Moderate Severe
Crouching/stooping	Mild Moderate Severe	Firm/Strong Grasping	Mild Moderate Severe
Lifting or Carrying	Mild Moderate Severe	Right only Left only Both	Mild Moderate Severe
10 lbs or less 11-25 lbs 26-50 lbs 51-75 lbs 76-100 lbs Over 100 lbs	Mild Moderate Severe	Mild Moderate Severe
Mild Moderate Severe	Mild Moderate Severe
Mild Moderate Severe	Fine motor, right hand	Mild Moderate Severe
Mild Moderate Severe	Fine motor, left hand	Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe

Level of Mental, Emotional and Sensory Limitation(s)
Pace of Work	Fast Average Below	Reasoning	Mild Moderate Severe
Manage Multiple Priorities	Mild Moderate Severe	Hearing	Mild Moderate Severe
Intense Customer Interactions	Mild Moderate Severe	Reading	Mild Moderate Severe
Multiple Stimuli	Mild Moderate Severe	Analyzing	Mild Moderate Severe
Frequent Change	Mild Moderate Severe	Verbal Communication	Mild Moderate Severe
Short-term Memory	Mild Moderate Severe	Written Communication	Mild Moderate Severe
Long-term Memory	Mild Moderate Severe	Vision	Mild Moderate Severe
Attention Span	Mild Moderate Severe

Section III - Medical Professional’s Comments

The above limitations are permanent. Yes No Comment:
Medical Professional’s signature:
Print Professional’s Name:	Date:

Please include additional documentation to support the request for accommodation as well as a cover letter on professional stationary. Return completed form to the Human Resources Office or fax to 540/568-7916.