Disability Programs and Resource Center
1600 Holloway Ave, Student Services Building, Room 110,
San Francisco, CA 94132-4046
Phone (415)338-2472 (voice/TDD) Fax (415)338-1041
TO:
Health Care Provider/Specialist
FROM:
Christina Valero, Administrative Analyst
RE:
_______________________
Employee’s Name
The above referenced employee has requested a reasonable accommodation under the Americans with Disabilities Act (ADA), and regulations promulgated by the Department of Fair Employment & Housing (DFEH). In order to determine whether this employee’s condition rises to the level of a “disability,” your assistance is needed. Please complete this form as fully as possible.
- Does this individual have a mental or physical impairment that limits one or more major life activities?
The determination of whether impairment exists is to be made without regard to mitigating measures such as medicines or assistive/prosthetic devices. Major life activities are such functions as “caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.” This list of major life activities is meant to be illustrative rather than exhaustive.
- Briefly describe how the individual is limited in major life activities.
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- Is the individual’s impairment temporary ____ or permanent ____?
- If the impairment is temporary, please indicate its expected duration.
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Signature ___________________________Date ___________________
(Please Print)
Name: ___________________________Title: _____________________
Address: _________________________Phone Number: _____________
Email: _________________________
If you have any questions or desire additional information, please do not hesitate to contact me at (415) 405-0333.
Revised : 08/03/03