Form 6042-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the employee's name in the first field, ensuring you include the last name, first name, and middle initial.
3. Next, input the physician's name in the second field, following the same format as above.
4. Provide the office contact telephone number in the designated field to ensure easy communication.
5. Fill out the physician's address completely, including street, city, state, and zip code.
6. In section five, detail the diagnosis of the requestor's current medical condition(s) clearly and concisely.
7. Outline the prognosis in section six, including future treatment plans and an estimated recovery date.
8. Indicate whether any impairments result from the medical condition(s) in section seven.
9. Describe the nature, severity, and duration of any impairments in section eight.
10. Specify which activities are limited by these impairments in section nine.
11. In section ten, explain how these impairments affect job functions required for the individual's current position.
12. Finally, provide a justification for reasonable accommodation requests in section eleven and ensure that all fields are completed before submitting.

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