ADA Accommodation Form Medical Professional Questionnaire 2026

1. Click ‘Get Form’ to open the ADA Accommodation Form Medical Professional Questionnaire in our platform.
2. Begin by filling in the Patient/Employee’s Name, including First, Middle Initial, and Last. This identifies the individual for whom accommodations are being requested.
3. Next, provide your details as the Medical Professional. Fill in your name, type of practice, medical specialty, business address, city, state, ZIP code, telephone number, and fax number.
4. In the Medical Information section, clearly identify the medical condition(s) requiring accommodations and specify the dates of treatment along with the probable duration of the condition.
5. Answer questions regarding any limitations in major life activities and essential job functions. Be specific about each limitation and its expected duration.
6. Indicate if any accommodations can be provided to help the employee perform their essential job functions effectively.
7. Complete any additional sections regarding leave requirements or episodic flare-ups that may affect job performance.
8. Finally, sign and date the form before submitting it back to DFA Human Resources via mail or fax as instructed.

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