Medical form request 2026

The document is a Medical Inquiry Form from Hostos Community College designed to assess an employee's disability in response to an accommodation request. It includes questions to determine the nature and extent of the impairment, its impact on major life activities and bodily functions, the limitations affecting job performance, and potential accommodations needed. The form aims to gather necessary information for providing reasonable accommodations while ensuring compliance with disability regulations.

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01. Edit your medical accommodation online
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Click ‘Get Form’ to open the medical inquiry form in the editor.
Begin by answering the initial questions regarding whether the employee has a physical or mental impairment. Select 'Yes' or 'No' as applicable.
If you answered 'Yes', specify the impairment and indicate if it is long-term or permanent. If not permanent, provide an estimated duration.
Next, assess whether the impairment substantially limits any major life activities. Check 'Yes' or 'No', and if applicable, list affected activities such as breathing, walking, or working.
Continue by evaluating if the impairment affects major bodily functions. Again, select 'Yes' or 'No', and detail any impacted functions.
Proceed to answer questions about job performance limitations and how they interfere with job functions.
Finally, provide any suggestions for accommodations that could enhance job performance and include any additional relevant information before signing.

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