Sample Medical Inquiry Form in Response to An

REASONABLE ACCOMMODATION REQUEST FORM

Nova Southeastern University - Office of Human Resources

Name: ______NSU ID: ______

Department: ______Supervisor’s Name: ______

Please provide the following information. Use additional pages as needed.
Identify your disability or physical or mental impairment(s) or limitations(s) (“Disability”).
Explain how your Disability impairs or limits your ability to perform assigned job duties (see attached Position Description).
What is the expected duration of the Disability?
What specific accommodation(s) are you requesting, if known?
If you are requesting a specific accommodation, how will it assist you to perform your job?
If you are not sure what accommodation is needed, do you have suggestions about what option(s) we can explore? / Yes ¨ / No ¨
If yes, please explain.
Is your accommodation request time sensitive? / Yes ¨ / No ¨
If yes, please explain.
Have you had an accommodation in the past for this same limitation? / Yes ¨ / No ¨
If yes, what was it and how did the accommodation(s) help you perform your job?
Please provide any additional information that may be useful in processing your request.
Please return this form with a medical documentation letter from your physician to support the accommodation requested. Guidance for medical professionals about how to provide documentation and a sample letter are provided in the attached JAN booklet titled, “Practical Guidance for Medical Professionals: Providing Sufficient Medical Documentation in Support of a Patient’s Accommodation Request”. Send the form with the medical documentation letter to the Office of Human Resources, attention to Diane Emery. Send by US mail to 3100 SW 9th Avenue, Fort Lauderdale, Florida 33315, by facsimile to (954) 262-6859, or by email to .
______
Signature Date