Healthcare Provider Request for Information (RFI) Form

Please return completed form to Amazon Disability & Leave Services (DLS).
Employees: upload to MyHR - Accommodations
Providers: Fax to 1-855-579-1799 or email to amazondls@amazon.com

Employee Portion
Name: _____________________________
Amazon Alias: ________________________
Date of Birth: ________________________
I authorize my healthcare provider completing this form, and my healthcare provider’s
agents and associates, to release medical information about me to Amazon, as needed to
enable Amazon to evaluate whether and how my medical condition impacts my ability to
perform my job duties and to further evaluate accommodations at work. I understand that
Amazon will treat this medical information as a confidential medical record consistent with
the Americans with Disabilities Act and any other applicable law. This authorization covers
subsequent requests by Amazon for clarifying and obtaining additional information relevant
to these subjects. I understand this authorization may expire under the laws of some states
after I sign it, but I agree to extend my authorization as needed for these purposes.

Signature of Employee or Representative ___________________________________________

Relationship to Employee (if signed by representative) ________________________________
Date Signed ___________________________________________

Healthcare Provider Portion

Below information to be completed by Healthcare Provider or their office only.
For purposes of this form, the “employee” referenced throughout refers to your patient
(name, date of birth above), who has requested reasonable accommodation related to their
workplace or employment. The intent of this form is to establish that this employee has
a qualifying disability or medical condition, and to identify restrictions and/or limitations
needed to evaluate the employee’s request. This medical documentation should describe the
nature, severity, and duration of the impairment, the activity/activities that the impairment
limits, and the extent to which the impairment limit’s the employee’s ability to perform the
activity/activities and should substantiate why the requested reasonable accommodation is
needed. Please complete all applicable portions of the form. If information is incomplete,
Amazon will likely need to contact your office to complete the form.

Section 1: Medical Condition

In this section, please provide information about the medical condition(s) that may impact
the employee’s ability to perform their job or that otherwise related to their employment.
1
Diagnosis is not required unless the underlying condition is pregnancy related , but diagnosis
can be helpful in the interactive reasonable accommodation process.

Does the employee have a disability or medical condition that impacts their work?
Return completed form to Amazon (DLS).
Employees: upload to MyHR - Accommodations. Providers: fax to 1-855-579-1799.
 ☐Yes (provide details below).
☐No. If you answer no, please explain how this accommodation request is connected to
the employee’s employment.

Is this request related to pregnancy or childbirth?

☐Yes, please provided expected date of delivery: __________________
☐No

Major Life Activities Impacted

A. Please indicate the major life activity impacted:
☐Sensory: Vision; Hearing; Speech; Other Sensory
#Mobility: Gross Motor/Sitting Standing, Walking, Lifting; Fine Motor/Dexterity; Other
Mobility
#Medical: Immunocompromised; Medical Device; Personal Medical Treatment
Administration; Other Medical
#Executive Functioning/Neurodiverse: Concentration; Learning; Comprehension;
Communication; Sensory; Other Executive Functioning
#Mental Health: Cognitive/Behavioral (memory, perception, expression, and/or
environmental sensitivity); Social Settings or Interactions; Interactions/Written, Verbal,
Other; Sensory or Other Triggers; Other Mental Health
#Other (describe major life activities impacted):
_________________________________________
_______________________________________________________________________________________________
B. Based on the above selection, please detail whether and how the medical condition(s)
above substantially impact major life activities. For example: If environmental
sensitivity, please describe any impact due to confined spaces, noisy environments, or
tolerating people interactions/exposure.
_______________________________________________________________________________________________
Section 2: Restrictions and Limitations
Describe the employee’s job-related restrictions/limitations (e.g. cannot stand for more
than X hours, cannot engage in repetitive motion, distracted by noisy environments, lighting
sensitivity). Please also explain specifically how the restrictions/limitations impact the
employee’s ability to perform their job duties or otherwise meet job-related requirements.
_____________________________________________________________________________________
_____________________________________________________________________________________
2a. Please also identify the anticipated duration of the restrictions/limitations.
☐ Start date: ____________________ End date: _________________________
☐ Greater than 6 months: If checked, please provide next office visit date
________________
Section 3: Accommodation Recommendation/Other Information
In Section 2, you provided details of their restrictions and limitations. Amazon’s interactive
accommodation process considers the job-related limitations of the employee’s condition and
needs of the business and role. We welcome recommendations from healthcare providers on
accommodations. Please use this section if you have accommodations to recommend, or any
other information you think we should consider in evaluating reasonable accommodations for
this employee.
Return completed form to Amazon (DLS).
Employees: upload to MyHR - Accommodations. Providers: fax to 1-855-579-1799.
 ☐Assistive technology or alternate formats (e.g., screen reader software, enlarged
monitor, speech to text software, push pads for doors, alternate keyboard or mouse).
Please describe:
_______________________________________________________________________________________________
☐Additional training (self), temporary job coach, or other individualized support.
☐Changes to work duration/time/schedule:
☐Specific shift/scheduling flexibility/reduced time. Please describe specifically:
_________________________________________________________________________________________
☐Additional breaks or ☐ Intermittent absences Please describe frequency and duration
_______ number of absences/breaks per ☐day ☐week ☐month ☐year
_______ number of ☐minutes, ☐hours, or ☐days per absence/break
☐No Overtime (hourly employees only)
☐No shift bid (hourly employees only)
☐Other. Please describe:
______________________________________________________
___________________________________________________________________________
☐Changes to work environment (work location or workstation set up). Please describe:
__________________________________________________________________________________
☐Changes to job functions.

Maximum amount Maximum

of time in Hours amount of weight
up to 5 lbs.
up to 10 lbs.
☐Carrying/Lifting up to 15 lbs.
up to 20 lbs.
☐Push/Pull up to 30 lbs.
up to 40 lbs.
up to 40 lbs. and
over
☐Squatting ☐ Bending ☐Reaching ☐ Gripping ☐Walking ☐Sitting
☐Standing ☐Climbing (e.g., use of ladder or ☐ of stairs/steps)
Please describe the
maximum amount of time
in hours:

☐ Other. Please describe:

______________________________________________________
___________________________________________________________________________
☐Changes to equipment operation.
☐Power Equipment (e.g. forklift, reach truck, scissor lift, etc.). Please describe the
specific limitation:
___________________________________________________________________________

Return completed form to Amazon (DLS).

Employees: upload to MyHR - Accommodations. Providers: fax to 1-855-579-1799.
 ☐Vehicles (e.g. van, truck). Please describe in specifics (maximum amount of time
in hours and maximum amount of weight):
___________________________________________________________________________
☐Working from heights. Please describe in specifics (maximum amount of time in
hours and maximum height):
___________________________________________________________________________
☐Other. Please describe:
______________________________________________________
___________________________________________________________________________
☐Other changes.
☐Working in extreme temperatures (e.g. freezer). Please describe the specific
limitation:
__________________________________________________________________________

☐Safety Equipment (e.g., safety shoe, gloves, other). Please describe in specifics:
__________________________________________________________________________
☐Other Please describe in specifics:
_________________________________________________________________________________________

Section 4: Healthcare Provider Signature and Contact Information

Please provide your stamp with information here or fill this out.

Healthcare Provider Name/Title: ______________________________________________________

Specialty: __________________________________________________________________________
Address: ___________________________________________________________________________
Phone: ____________________________________ Fax: ___________________________________
Signature: _______________________________________ Date of Evaluation:
________________

Endnotes
1
The Pregnancy Workers Fairness Act (PWFA) is a federal law that applies specifically to
accommodation for pregnancy-related conditions. In order to determine whether this law applies,
Amazon needs to know if the accommodation request is due to a pregnancy-related condition.

Return completed form to Amazon (DLS).

Employees: upload to MyHR - Accommodations. Providers: fax to 1-855-579-1799.