RSS icon

Top Stories

Documenting Applicant_Employee Medical Review

April 1, 2000
Related Topics: Disabilities, Featured Article
Reprints
This form is filled out by the physician or medical examiner to provide input to the employer about the employee's medical condition.

CONFIDENTIAL INFORMATION, ACCESS LIMITED TO:


APPLICANT / EMPLOYEE MEDICAL REVIEW

 

Physician, please complete this form and return to:

Employer: _________________________________
Attention: _________________________________

Address/Telephone:__________________________
__________________________________________

Including any pertinent medical reports by:
______________________.

Thank you.

Medical information may be required to determine if the individual meets the ADA definition of an individual with a disability and is entitled to an accommodation. EEOC TAM 6.6 Additionally, the employer may request medical documentation of functional limitations to support an accommodation request. EEOC TAM 3.6

 

Applicant / Employee Name:
__________________________________________________________

Job Title:
__________________________________________________________

 

Medical Review

I have reviewed the job description for this job title and examined the applicant/employee and it is my opinion that:

Applicant / Employee is currently able to perform all job functions described without posing a direct threat to the safety of self or others.   Yes ____    No _____

IF NO, Applicant / Employee has the following limitations in relation to described job functions.

Functional Limitation(s)  Duration

(Please be specific in your description)   (State period of time)

_________________________________________________   _________________________
_________________________________________________   _________________________
_________________________________________________   _________________________
_________________________________________________   _________________________

Medical Diagnosis:
____________________________________________________________

Additional Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

 

 

Please complete the risk assessment portion on Page Two of this form

The assessment of risk must be based on reasonable medical judgment that relies on the most current medical knowledge and/or the best available objective evidence. EEOC TAM 4.5(4).

It is my opinion that the applicant/employee meets the health and safety requirements of this position.   Yes ___    No ____
(If no, complete the following section)

 

DIRECT THREAT RISK ASSESSMENT

The following factors must be considered in respect to the specific aspect of the disability that would pose a direct threat . The risk may not be speculative or temporary. It must be a significant risk of substantial harm. EEOC TAM 4.5(2)

(Please complete the following statements.)

Aspect of disability causing risk is: ____________________________

The type of harm this risk will cause is: __________________________
__________________________________________________________

(Check all statements that apply.)

______ The aspect of disability described will pose a risk for an extended period of time.

______ The resulting harm from this risk will be substantial.

______ It is highly probable that this harm will occur.

______ This significant risk of substantial harm is current or immediate.

Comments:
__________________________________________________________
__________________________________________________________
__________________________________________________________

Optional: Did the applicant and/or can you suggest any accommodations that could reduce or eliminate the health or safety risk and assist the individual to perform the essential functions of the job safely?
__________________________________________________________
__________________________________________________________
__________________________________________________________

Physician Signature
__________________________________________________________

Date _________________________

Medical Specialty
__________________________________________________________

The information and forms contained in this feature are intended to provide useful information on the topic covered, but should not be construed as legal advice or a legal opinion.

Recent Articles by Robert Hall

Comments powered by Disqus

Hr Jobs

Loading
View All Job Listings