LAC 22:I.205 – Medical Inquiry Form

MEDICAL INQUIRY FORM

CONFIDENTIALITY STATEMENT:A request for accommodation, including medical and other relevant information, is privileged and may only be released as appropriate to individuals with a business need to know.CONFIDENTIALITY STATEMENT:A request for accommodation, including medical and other relevant information, is privileged and may only be released as appropriate to individuals with a business need to know.RESPONSIVE TO ACCOMMODATION REQUEST

FOR COMPLETION BY EMPLOYEE

Employee’s Name: _______________________________________

Authorization for Release of Medical Information

I authorize my Healthcare Provider to release medical information that is specifically related to and necessary for my employer to determine whether I have a disability for which an accommodation(s) may be needed. I authorize my Healthcare Provider to speak directly to my Agency ADA Coordinator in regards to my medical condition and its effects upon my ability to perform the essential functions of my job. I understand that I may refuse to sign this Authorization. However, I understand that my failure to permit these disclosures may impact my employer’s ability to fully address my request for accommodation.

Employee’s Signature: _____________________________________________ Date: _______________

FOR COMPLETION BY HEALTHCARE PROVIDER

SECTION 1: Questions to determine whether employee has a disability

For reasonable accommodation under the Americans with Disabilities Act (ADA), an employee has a disability if he/she has an impairment that substantially limits one or more major life activities or has a record of such an impairment. The following information may help to determine whether an employee has a disability:

Does the employee have a physical or mental impairment?

Yes (proceed to section A. below) No (discontinue completion of form)

A. What is the impairment or the nature of the impairment? ___________________________________________

_______________________________________________________________________________________

B. Does the impairment substantially limit a major life activity as compared to the general population?

Yes No

C. What major life activity(s) and/or major bodily function(s) is limited?

Major Life Activities:

Bending	Eating	Lifting	Seeing	Standing
Breathing	Hearing	Performing Manual Tasks	Sitting	Thinking
Caring for Self	Interacting with Others	Reaching	Sleeping	Walking
Concentrating	Learning	Reading	Speaking	Working
Other:

Major Bodily Functions:

Bladder	Circulatory	Hemic	Neurological	Respiratory
Bowel	Digestive	Immune	Normal Cell Growth	Special Sense Organs & Skin
Brain	Endocrine	Lymphatic	Operation of an Organ
Cardiovascular	Genitourinary	Musculoskeletal	Reproductive
Other:

D. Describe any functional limitations caused by the impairment: _______________________________________

_______________________________________________________________________________________

SECTION 2: Questions to help determine whether an accommodation is needed.

An employee with a disability is entitled to an accommodation only when the accommodation is needed because of the disability. The following information may help determine whether the requested accommodation is needed because of the disability:

_______________________________________________________________________________________

Health Care Provider’s Signature: _______________________________________ Date: __________

Health Care Provider’s Name (Printed): _____________________________________

Practice Specialty: ______________________________________________________

Clinic Name: ___________________________________________________________

Address: ______________________________________________________________________________________

Telephone #: ____________________________________ Fax #: __________________________________

RETURN COMPLETED FORM DIRECTLY TO [INSERT NAME], AGENCY ADA COORDINATOR

By Fax to: (225) 342-XXXX; or, email to:

Authority Note

A. What job duties is the employee unable to perform or having difficulty performing?

Authority Note

B. How does the employee’s functional limitation(s) interfere with his/her ability to perform required job duties?

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 16:225, et seq.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Public Safety and Corrections, Corrections Services, LR 26:1312 (June 2000), amended LR 49:500 (March 2023).