ADA Request for Reasonable Accommodations Healthcare Provider Form 2025

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An employer may use this form to document the determination of an employees request for a reasonable accommodation under the Americans with Disabilities Act (ADA).
For that reason, a flexible or modified schedule is one of the most common accommodations under the ADA. What exactly flexible means in this context can vary. Some workers may get adjusted start or end times, reduced hours, or permission to take extra breaks for medical needs.
The provider does not have to be a medical doctor (MD). Examples may include doctors (including psychiatrists), psychologists, nurses, physical therapists, occupational therapists, speech therapists, vocational rehabilitation specialists, and licensed mental health professionals, among others.
The ADA Questionnaire is a basic resource employers should utilize to determine if an employee is eligible for protection under the Americans with Disabilities Act (ADA), as amended.
Dear [Insert employers name here]: I am writing this letter to submit a request for accommodations in the workplace. I have pain in my lower back. Sitting or standing for long periods of time in the same position is causing increased pain and is decreasing my mobility.
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