Letter to Doctor Re Disability & Accommodation

LETTER TO DOCTOR RE DISABILITY & ACCOMMODATION

[Date] [Doctor's name & address] Re: [Employee] Dear Dr. [Name]: I am writing to you with regard to our employee and your patient, [employee]. As you know, [employee] sought medical treatment because of [identify circumstances leading to treatment, such as: a work-related shoulder injury that occurred last month; or: a nervous condition that appeared to cause a loss of memory]. The purpose of this letter is to explain the nature of [employee]'s job and to request your assistance in determining whether [he or she] is disabled within the meaning of applicable laws and whether [he or she] is able to perform the essential functions of [his or her] job with or without a reasonable accommodation. The employee's job description is: [Insert job description.] The essential functions of the job include: [Identify required tasks the employee must perform and their frequency, physical capabilities, mental capabilities, emotional capabilities, social skills, availability for work requirements, environmental tolerances, and so on, that are necessary to perform the employee's job.] As you know, under disability discrimination laws, an individual has a disability if the individual suffers from a physical or mental impairment that limits a major life activity. With this in mind, please answer the following questions: 1. Is [employee] able to perform the job without accommodation? __ Yes __ No If the answer is "Yes," please skip to question 6. If the answer is "No," please continue: 2. Is [employee] disabled? __ Yes __ No 3. If the answer to question 2 is "Yes," could you describe how [employee]'s impairment relates to the essential functions of the job and indicate how long you expect the impairment to last?

4. Would a reasonable accommodation allow [employee] to perform the job? __ Yes __ No

Form 9382-1-1 Letter to Doctor re Disability & Accommodation Page 1 of 2 Copyright 2003 LawRoom 5 If the answer to question 4 is "Yes," what reasonable accommodation would allow [employee] to perform the job?

6. If [employee] is able to do the job with or without accommodation, could you describe any safety risks to [employee] or to others that may result from [employee]'s condition?

When you have answered these questions, please mail or fax your answers to me at the address or fax number indicated above. Thanks very much for taking the time to assist us. Of course, if you need any further information, please do not hesitate to call. Sincerely,

[Name & title]