Health Care Professional Statement on Employee
Accommodation Request

Cheryl Bressington, Human Resources Director, (308) 865-8388
(Complete form onscreen, print, sign and submit to UNK Human Resources)

Employee Name

Physician/Psychologist

I. Diagnosis Information:
If the diagnosis is psychiatric, please include DSM-IV classification:
(Press Enter/Return at the end of each line)
 

Medical/Psychiatric test conducted that support diagnosis:
(Press Enter/Return at end of each line)
 

If diagnosis is learning disability, please include breakdown of scores from test:
(Press Enter/Return at the end of each line)
 

Current medication that could require accommodation for side effects:
(Press Enter/Return at the end of each line)
 

II. Determination of Disabiling Condition:
In your medical judgement is the patient substantially limited in a major life activity because of an impairment at the present time? YesNo

If yes, what is the major activity?
Walking
Speaking
Breathing
Hearing
Seeing
Concentrating
Lifting
Working
Learning
Thinking
Performing Manual Tasks
Interacting with Others

Please discuss how the patient is limited in the major life activity identified above. If the major life activity is 'working' identify some jobs that he/she could not perform because of the impairment.*
(Press Enter/Return at end of each line)
 

III.Determination of Impact on Job Functions:)(To be completed by Human Resources-Press Enter/Return at end of each line)
 

Essentail job functions as presently performed. Please indicate if patient is able to perform each of these job functions (Y); cannot perform the job function (N); or requires accommodation (A).
(Press Enter/ Return at end of each line)
 

Thank you for providing us with the benefit of your expertise. Please sign and date this form and return it with the appropriate medical documentation to John Lakey, Director, Human Resources, University of Nebraska at Kearney, Kearney, NE 68849.


_________________________________________________
Physician/Psychologist Signature and Date

*This information is requested to determine whether there is a class of jobs or a broad range of jobs the individual cannot perform to be used in the determination of substantially limited in this category.