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ADA Interactive Process Health Care Provider Questionnaire

ADA Interactive Process Health Care Provider Questionnaire 2025

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The document is a questionnaire designed for physicians or qualified health care providers to assess whether an employee has a disability under the Americans With Disabilities Act (ADA). It aims to gather information about the patient's medical condition, its impact on major life activities and job functions, and any necessary accommodations that could enable the patient to perform their job effectively. The form includes sections for patient information, limitations, potential accommodations, and certification by the health care provider.

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Click ‘Get Form’ to open the ADA Interactive Process Health Care Provider Questionnaire in our editor.
Begin by filling out Section A: Patient Information. Enter the employee/patient's name and answer whether they have a physical or mental impairment. If yes, specify the impairment.
Provide details on when the patient first experienced their medical condition and its expected duration. Clearly indicate if it is permanent or temporary.
Assess if the patient's condition limits their ability to perform major life activities. If yes, list all affected activities as prompted.
Describe any workplace activities the patient is unable to perform due to their impairment, including severity and expected duration of limitations.
In Section B: Accommodations, indicate if you know of any job modifications that could assist the patient in performing their job functions.
Complete the certification section by signing and providing your details as a health care provider.

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