Decatur, TX · Wise County
ADA Job Accommodation Request and Medical Inquiry Form
This form helps the City assess an employee’s accommodation request and is completed by the employee’s health care provider.
What this form is
The City uses this form to help determine whether an employee with a disability needs a reasonable accommodation to perform essential job functions safely and effectively. The employee’s health care provider answers questions about impairments, limitations, job-related difficulties, and possible accommodations. The form instructs the provider to complete each section, sign and date it, and attach additional pages as needed.
Who needs it
A City employee requesting a job accommodation and the employee’s attending health care provider need to complete the related request and medical inquiry materials.
How to submit it
The form instructs the health care provider to fax the signed and dated original using the contact information below; it does not specify a fax number in the provided text.
About notarization
This document is signed without a notary; the form calls for the health care provider’s signature and date and mentions an attached employee request and medical release authorization, not a sworn attachment.
How to submit this form
- 1
Download The Form
Download the ADA Job Accommodation Request and Medical Inquiry Form.
- 2
Complete The Form
Have the employee’s attending health care provider complete each section and provide information related to the employee’s ability to perform job duties.
- 3
Gather Attachments
Attach the employee’s request and medical release authorization; add pages as needed.
- 4
Sign And Submit
Have the provider sign and date the form, then fax the signed original using the contact information below.
Frequently asked questions
- What is the ADA Job Accommodation Request and Medical Inquiry Form for?
- It helps the City determine whether an employee with a disability needs a reasonable accommodation to perform essential job functions safely and effectively.
- Who completes this form?
- The employee’s attending health care provider completes the medical inquiry, signs and dates the form, and may attach additional pages. The employee’s request and medical release authorization are attached.
- Do I need a notary for the ADA Job Accommodation Request and Medical Inquiry Form?
- No. This form calls for the health care provider’s signature and date, not notarization. It mentions an attached employee request and medical release authorization but does not say those attachments must be notarized or sworn.
- How do I submit the ADA Job Accommodation Request and Medical Inquiry Form?
- The form instructs the provider to fax the signed and dated original using the contact information below. The provided text does not include a fax number.
Need something notarized?
This ADA Job Accommodation Request and Medical Inquiry Form doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.