Appendix B - DHS HQ Medical Statement Form 2025

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Physical or mental impairments include, but are not limited to: visual, speech, and hearing impairments; mental retardation, emotional illness, and specific learning disabilities; cerebral palsy; epilepsy; muscular dystrophy; multiple sclerosis; orthopedic conditions; cancer; heart disease; diabetes; and contagious and
This form is commonly used to obtain information from a healthcare provider to substantiate that an employee has a medical impairment, associated limitations, and requires accommodation under the ADA.
Sufficient medical documentation should describe the nature, severity, and duration of the impairment, the activity or activities that the impairment limits, the extent to which the impairment limits the employees ability to perform the activity or activities, and should also substantiate why the requested reasonable
Sample Reasonable Accommodation Statements: If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [include name and/or department, telephone, and e-mail address].
For example, maybe the employer needs more information about your disability and how your limitations or restrictions affect your ability to perform the essential duties of the job. Or perhaps the accommodation you requested isnt reasonable or will cause an undue hardship for the employer.
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The ADA requires reasonable accommodations as they relate to three aspects of employment: 1) ensuring equal opportunity in the application process; 2) enabling a qualified individual with a disability to perform the essential functions of a job; and 3) making it possible for an employee with a disability to enjoy equal

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