Tip for N/A (employer-specific)

The documentation should focus on functional limitations — not just the diagnosis name

Tip for N/A (employer-specific)

Your employer can only ask for information related to the specific accommodation request

Tip for N/A (employer-specific)

If your employer denies the accommodation, ask for the denial in writing with their reasoning

Employment / FMLAmoderateDoctor signature required

Medical Documentation for ADA Accommodation

N/A (employer-specific) · Employers

Medical documentation supporting the need for workplace accommodation. Must describe functional limitations without requiring disclosure of specific diagnosis. Employer must keep confidential.

Form Details

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Where to Submit This Form

📬

Return to your employer's HR department

Submit along with or after your accommodation request.

📧

Email to HR if accepted electronically

Filing Deadline

Typically within 15-30 days of your employer's request for documentation. Your employer should specify their timeline.

Required Attachments

📎 Completed by your treating physician or licensed healthcare provider
📎 Description of the disability and how it limits major life activities or job functions
📎 Recommended accommodations from a medical perspective
📎 Expected duration of the condition and accommodation need

Processing Time

Part of the ADA interactive process. Employer should respond promptly after receiving documentation.

What Happens Next

Your employer will review the documentation as part of the interactive process. They may approve the requested accommodation, propose alternatives, or request additional clarification.

Tips for This Form

✓ The documentation should focus on functional limitations — not just the diagnosis name
✓ Your employer can only ask for information related to the specific accommodation request
✓ If your employer denies the accommodation, ask for the denial in writing with their reasoning
✓ Your medical information must be kept confidential and in a separate file from your personnel file

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