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Below is a template for an ADA (Americans with Disabilities Act) form that a doctor or healthcare provider might use in a workplace setting. This template provides a structure that can be adapted to specific needs and situations.
A sample form for a health care provider to complete when an employee requests an ADA accommodation.
Get up to speed with the ADA reasonable accommodation and learn how to manage requests. Download our free checklist template and request form for HR!
ADA Medical Certification. University of Richmond Americans with Disabilities Act (ADA) Employee Accommodation Medical Certification Form. To be completed by Health Care Provider. SECTION I: For Completion by the EMPLOYEE. Your Name: _________________________________________________________________________________ First MI Last UR ID Number.
Date: _____________________________________________________________. A sample form for an employee to request an accommodation due to disability.
This template is designed for employees or applicants to formally request accommodations for disabilities as per the Americans with Disabilities Act (ADA) and the Rehabilitation Act, detailing their specific needs, impairment nature, desired accommodations, and necessary medical documentation (employees only).
To Health Care Provider: Please complete this form in full. This questionnaire is part of an interactive process that is necessary in order to determine if your patient (our employee) has a disability recognized under the Americans With Disabilities Act,
