ADA Questionnaire for Physician 2026

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The document is a formal request from an employer to a physician for information regarding an employee's potential disability under the Americans With Disabilities Act (ADA). It seeks the physician's input on whether the employee has a physical or mental impairment that substantially limits major life activities, which may affect their job performance and safety. The employer aims to determine if reasonable accommodations are necessary for the employee to perform essential job functions. A questionnaire is included to facilitate the physician's assessment.

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Click ‘Get Form’ to open the ADA Questionnaire for Physician in our editor.
Begin by filling in the introductory section, including the patient's name and relevant details about their employment and medical condition.
Proceed to the Disability Questions section. Answer question 1 regarding whether recent episodes are due to a physical or mental impairment. If 'Yes', provide specifics in question 2.
For questions 3 through 8, detail how the impairment affects major life activities, its duration, and any suggested accommodations needed for the employee.
Move on to the Safety Questions section. If applicable, identify any current risks associated with the employee's disability and describe potential accommodations that could mitigate these risks.
Finally, ensure all fields are completed accurately before signing and dating the form at the bottom.

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