REQUEST TO MEDICAL PRACTITIONER FOR ADAAA ASSESSMENT OF EMPLOYEE ABILITY TO PERFORM JOB FUNCTIONS

(From Employer To Physician)

Physician:

Employer:

Date:

Our employee, [Name of Employee], is employed as a [Position Title] at [Site or Facility].

We need your medical expertise in determining whether the employee is capable of performing [his/her] job duties, with or without reasonable accommodation.

You will find three documents attached.

1. The employee’s disclosure for you to share health information with us. [Note to employer: Have employee complete this form before including.]

2. A Response for ADAAA Assessment Form, which you can use to supply us with the information we are requesting.

3. The employee’s job description, which separates essential functions from marginal functions.

General instructions for medical practitioner: Since we are required to comply with the Americans with Disabilities Act (ADAAA) and similar state requirements, please take into account the following information when providing information about the employee.

·  First evaluate the employee’s physical and/or mental ability to perform essential job functions.

·  Then separately evaluate the employee’s physical and/or mental ability to perform marginal functions.

·  Give us an overall evaluation of the employee’s ability to function in [his/her] current state as a member of our workforce.

·  Indicate whether the employee could constitute a direct threat to [himself/herself] by performing the essential or the marginal functions of the job. “Direct threat” means a significant risk of substantial harm to the health or safety of the individual or of others.

Other special health requirements are (describe):

Other job-related business necessity requirements (describe):

EMPLOYEE/PATIENT INFORMATION
AND INFORMED CONSENT FOR DISCLOSURE OF HEALTH CARE INFORMATION
Employee's Name:
Employee's Address:
City, State, Zip: Telephone Number:
HIPAA and GINA COMPLIANT AUTHORIZATION TO RELEASE INFORMATION:
By completing this document, I demonstrate my informed consent and authorization to allow the physician or practitioner identified on this form to release and disclose to ______ such health care records and information concerning my current medical condition as is necessary to support my request for potential disability accommodations. This authorization is made per my request. This authorization shall be valid for one (1) year from the date shown below, unless revoked by me in writing at an earlier date. Although I understand that I may revoke this authorization in writing at any time, I also understand that any such revocation will not apply to any information that has already been released in reliance on this authorization, and that any revocation may have an adverse effect on the receipt of employer-provided benefits. I understand that my medical treatment is not conditioned upon me providing this authorization. I understand that information disclosed by the physician or practitioner to the employer may be subject to re-disclosure and not protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I also understand that in accordance with the Genetic Information Non-Discrimination Act the Company is not requesting nor should the health care provider furnish any information related to your family medical history.
Employee Signature: ______Date:
Alternatively, signature of Personal Representative and statement of authority to act on behalf of individual:
______Date:


RESPONSE FOR ADAAA ASSESSMENT FORM

The employee is is not able to perform the essential functions of [his/her] position.

If not able, the essential functions that physically or mentally cannot be performed are:

Are you aware of any measures the employee or the employer can take to enable the employee to perform the described essential functions? Yes No

If yes, explain:

The employee is is not physically or mentally able to perform the marginal functions of the job.

If not able, the marginal functions that physically or mentally cannot be performed are:

Are you aware of any measures the employee or the employer can take to enable the employee to perform the described marginal functions? Yes No

If yes, explain:

The employee’s performance of job duties would would not constitute a direct threat to the employee or to others.

If a direct threat would exist:

1. indicate if the threat would result from performing an essential or a marginal function:

2. specifically describe the nature of the threat, its severity, the probability of it occurring and when, and its duration:

3. describe any accommodations that might alleviate, in whole or in part, the threat:

I would would not recommend further medical evaluation as to the employee’s present abilities to perform the described job functions and whether [he/she] would represent a direct threat by such performance.

The following tests and/or evaluations were conducted:

Name of Health Care Provider:

Signature:

Date:

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information.“Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.