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DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 <br /> ii <br /> CONFIDENTIAL <br /> 4. Please describe the functional limitations and the"major life activity" or activities <br /> affected. <br /> 4 <br /> a <br /> 5. Please indicate your professional opinion as follows: <br /> The employee should be able to perform the essential job functions <br /> WITHOUT any accommodations. <br /> The employee is not able to perform the essential job functions and a <br /> reasonable accommodation is not advised/feasible. <br /> The employee should be able to perform the essential job functions <br /> WITH reasonable accommodations. Based on your professional opinion, <br /> Please provide the specific accommodations recommended for <br /> consideration by the Company <br /> f <br /> G <br /> r <br /> 6. If appropriate, please indicate any actions necessary for the protection of the health <br /> and safety of the employee and other employees and any special instructions for first- <br /> u <br /> aid providers and supervisors.. <br /> Health Care Provider(Print) Address <br /> Area of Medical Specialty Phone Number <br /> Signature <br /> 107353A <br />