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DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 <br /> CONFIDENTIAL <br /> EMPLOYERS' REQUEST FOR MEDICAL INFORMATION TO SUPPORT EMPLOYEE'S <br /> REQUEST FOR REASONABLE ACCOMMODATION' <br /> Dear Physician: <br /> Our employee, ,has informed us that(s)he has a physical or <br /> mental impairment, condition, or disease and that (s)he needs the company to reasonably <br /> accommodate him/her so that(s)he can perforrn the essential functions of his/her job. We are <br /> including a copy of[NAME OF EMPLOYEE]'s written request for reasonable <br /> accommodation. [NAME OF EMPLOYEE] also has authorized the company to obtain medical <br /> information from your office in support of his/her request for reasonable accommodation. We <br /> also are including a copy of[NAME OF EMPLOYEE'S] authorization for release of medical <br /> information. <br /> t <br /> [NAME OF EMPLOYEE] holds the position of[POSITION]. The essential functions of the <br /> position are [OPTION: (1)LIST ESSENTIAL FUNCTIONS; OR"listed in the attached job <br /> description."]. <br /> I <br /> [NAME OF COMPANY] appreciates your office's cooperation and assistance in our evaluation <br /> of[NAME OF EMPLOYEE'S] request for reasonable accommodation. Please return this <br /> document to us by mail at [ADDRESS], confidential fax at [CONFIDENTIAL FAX <br /> NUMBER], or electronic correspondence in PDF form at [EMAIL ADDRESS]. If your office <br /> has any questions about this form, we may be reached at [NAME, POSITION,AND PHONE <br /> I <br /> NUMBER]. <br /> 1. Does the employee have a health condition/disability that results in a physical or <br /> mental impairment that limits one or more"major life activities"? Major life <br /> activities include by are not limited to breathing, walking, hearing, seeing, working, <br /> and reproduction. <br /> Yes No <br /> E <br /> 2. If the answer to Question 1 is "yes",please describe the employee's current health <br /> condition/disability. <br /> E <br /> �r <br /> 3. Please provide date condition/disability commenced. What is estimated duration of <br /> condition/disability? <br /> I <br /> f <br /> k <br /> i` <br /> i <br /> 'NOTE TO EMPLOYER:This form must be kept in a separate file that is not part of the personnel file. <br />