Sample Post-ADA Amendments Interactive Process Questionnaire   

A sample interactive process questionnaire designed to be used when an employee with a disability requests an accommodation after the ADA Amendments Act of 2008 goes into effect (January 1, 2009)

Explanation:

This questionnaire is designed to be used when an employee with a disability requests an accommodation after January 1, 2009, which is the date that the ADA Amendments Act becomes law. The ADA Amendments Act fundamentally alters the landscape of disability law and the reasonable accommodation process. At some point in the near future, the EEOC will publish new regulations impacting the reasonable accommodation process, which will likely require employers to modify this questionnaire.

To: Dr. Healthcare Provider, M.D.

Name of Employee: John Doe

Job Evaluated: Truck Driver

Please answer and return the following questionnaire to your patient within the time frame indicated. The questionnaire format is a guide and we would appreciate a response to every question. We need your complete medical opinion, so please feel free to include a more detailed narrative response to any and all questions if needed to answer more fully. Thank you for your anticipated cooperation.

IMPORTANT NOTE TO HEALTH CARE PROVIDER: When answering these questions, please do not take into consideration any ameliorative effects of mitigating measures, such as medications, medical supplies, equipment, or appliances, low-vision devices (which do not include ordinary eyeglasses or contact lenses), prosthetics including limbs and devices, hearing aids and cochlear implants or other implantable hearing devices, mobility devices, or oxygen therapy equipment and supplies; use of assistive technology; reasonable accommodations or auxiliary aids or services; or learned behavioral or adaptive neurological modifications.

1. Does Mr. Doe have a physical or mental impairment?     Yes         No

If so, please state the type of impairment: ________________________________________________________________________

________________________________________________________________________

2. Does Mr. Doe’s impairment substantially limit any major life activities?     Yes        No

3. If so, which major life activity or activities are limited? ________________________________________________________________________

________________________________________________________________________

4. For each major life activity that is limited by the impairment, please describe how Mr. Doe is restricted as to the condition, manner, or duration under which that activity can be performed, as compared to the way in which an average person in the general population can perform that activity:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

5. What is the duration or expected duration of Mr. Doe’s impairment? ________________________________________________________________________

________________________________________________________________________

6. Attached is a job description for the truck driver position. Please review the job description and assess whether Mr. Doe can perform all job functions:         Yes         No

7. If not, which job functions can not be performed, and why not? ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

8. Please describe any reasonable accommodations that would allow this employee to be able to perform those job functions:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

9. If medical leave is one of the possible accommodations listed above, please provide an estimated duration for the leave:

________________________________________________________________________

10. Would performing any of the job functions listed result in a direct safety or health threat to this employee or other people (co-workers, members of the general public, etc.)?

                                                                                Yes         No

11. If yes, please describe:

which job function(s) would pose such a threat: ________________________________________________________________________

________________________________________________________________________

the direct safety or health threat posed: ________________________________________________________________________

________________________________________________________________________

any reasonable accommodations that would eliminate the direct safety or health threat, or reduce it to an acceptable level: ________________________________________________________________________

________________________________________________________________________

 _________________________         __________________              _________________

Signature                                                Title                                          Date

Printed Name and Address:

______________________________________________

______________________________________________

______________________________________________

This questionnaire was provided by Richard Meneghello of the law firm of Fisher & Phillips LLP (www.laborlawyers.com; Suite 1250, 111 SW Fifth Avenue, Portland, Oregon 97204; (503) 242-4262).

Reprinted with permission. © CCH