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Sample Documentation for Workplace Accommodations

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This handout includes sample documentation healthcare professionals can customize for patients who are seeking workplace accommodations. There are three samples of different workplace accommodation letters—the first one is a more general letter, the second is an example that could be used for a patient with ADHD, and the third is an example that requests a leave of absence.

The footnotes within the first letter offer additional information and instructions for helping you draft an accommodation letter for your patients.

To learn more about this topic, including four things healthcare professionals need to know, check out our Medical Documentation for Accommodation Requests video.

Sample Letter: General

[Date]

To Whom It May Concern:

Our patient [NAME] has [DIAGNOSIS],[1] and has been a patient of ours for [LENGTH OF TIME]. This condition—when viewed in its active state, and without considering mitigating measures like medications and therapies—substantially limits at least one bodily function or major life activity, as compared to most people, including [BODILY FUNCTION/MAJOR LIFE ACTIVITY].[2]

It is my understanding that the patient works for you in the position of [JOB TITLE]. From the information provided, I believe that the patient can continue to perform this job, but has certain restrictions, namely [RESTRICTIONS/FUNCTIONAL LIMITATIONS].[3] As a result, I recommend that certain reasonable accommodations be made at work, as follows: [LIST OR DESCRIBE ACCOMMODATIONS].[4] It is expected that such accommodations should remain in place until [DATE].[5]

This patient is compliant with treatment recommendations and is able to manage the above condition, and can continue to work with reasonable accommodations as described above.

Thank you very much for your consideration.

[SIGNATURE]
[PRINTED NAME AND CREDENTIALS]

[1] List the relevant diagnosis or diagnoses contributing to the need for workplace adjustments.

[2] There is no exhaustive list, but bodily functions may include immune, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, reproductive, genitourinary, cardiovascular, hemic, lymphatic, and musculoskeletal functions; functions of sense organs and skin; normal cell growth; or the operation of an individual organ within a body system (e.g., the operation of the kidney, liver, pancreas, or other organs). Major life activities may include caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, writing, concentrating, thinking, communicating, sitting, reaching, and interacting with others. Working is also a major life activity but it has a special definition, and normally does not need to be listed.

[3] List only the ones that impact the patient’s particular job.

[4] There is no exhaustive list of reasonable accommodations. Some common ones include a finite period of leave, a schedule change, lifting restrictions, use of a service animal, or assistive devices and technology. But there are many others. The Job Accommodation Network (JAN) website has a helpful resource page that includes a list of accommodation options by type of disability. If possible, avoid requesting open-ended or indefinite leave; instead, give a probable return-to-work date. Other requests to avoid are for a new supervisor, “stress-free” work, or permanently lowering production standards. Creation of a new job is normally not required, but transferring the individual to a vacant position may be.

[5] In some cases the need for accommodations will be permanent.

Sample Letter: Patient with ADHD

[DATE]

To Whom It May Concern:

Our patient Juan Pérez has an injury to the rotator cuff in his right shoulder, and it requires surgery, physical therapy, and a period of recovery.

His condition—when viewed in its active state, and without considering mitigating measures like surgery, medications, and therapies—substantially limits at least one bodily function or major life activity, as compared to most people, including his musculoskeletal functions and his ability to bend and lift.

It is my understanding that the patient works for you in the position of Mechanic II. From the information provided about his job, I believe that the patient can continue to perform this job, but he will need a reasonable period of leave, for the reasons stated above. I am requesting that he be allowed leave until December 15, 2021, when I expect that he will be able to return to his job with a lifting restriction of 25 pounds, and he should be able to return without restrictions by January 15, 2022.

This patient has been compliant with treatment recommendations and is able to manage the above condition, and can continue to work with reasonable accommodations as described above.

Thank you for your consideration in this matter.

[SIGNATURE]
[PRINTED NAME AND CREDENTIALS]

Sample Letter: Request Leave of Absence

[DATE]

To Whom It May Concern:

Our client Roberta Roe has Attention Deficit-Hyperactive Disorder (AD/HD). This is a neurodevelopmental disorder that affects three to five percent of Americans. Ms. Roe’s condition—when viewed in its active state, and without considering mitigating measures like medications, therapies, and other accommodations—substantially limits at least one bodily function or major life activity, as compared to most people, including concentrating, thinking, and neurologic or brain function.

It is my understanding that Ms. Roe works for you in the position of Customer Service Specialist. I am confident that she can continue to perform all of the essential duties of this job, with the benefit of certain reasonable workplace accommodations, including the use of a noise-cancelling headset, and a workstation positioned away from other employees and visual distractions, or perhaps with a door added to her cubicle.

With these accommodations (or ones like them), Ms. Roe should be able to successfully manage her condition, and be successful in her job.

Thank you for your consideration in this matter.

[SIGNATURE]
[PRINTED NAME AND CREDENTIALS]

Publication Code: EM17


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Disclaimer: Disability Rights Texas strives to update its materials on an annual basis, and this handout is based upon the law at the time it was written. The law changes frequently and is subject to various interpretations by different courts. Future changes in the law may make some information in this handout inaccurate.

The handout is not intended to and does not replace an attorney’s advice or assistance based on your particular situation.


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