Accommodation Request Assessment Form
DATE:
REGARDING: Employee Name: Erlin Salazar
Employee DOB: 11/18/1998
COMPLETED FORM MUST BE RETURNED TO PARTNER Alight NAME
The above employee has requested a workplace accommodation, either because of a potential disability under the
Americans with Disabilities Act (ADA) or state anti-discrimination law, or because the employee is pregnant and
seeks an accommodation under an applicable pregnancy accommodation law. The information requested on this
form will assist us in making a determination regarding the employee’s request.
INSTRUCTIONS: The following form must be completed in detail and signed by the employee’s attending medical
provider. Please attach additional pages or records as needed. Do not provide information that is not related to
the employee’s ability to perform his/her job duties. Example: Do not identify an impairment if it does not have
an impact on the employee’s ability to perform his/her job duties. For California employees who are pregnant
without an underlying medical condition and are only seeking a workplace accommodation and not a leave of
absence, please complete only questions 1, 2, and 10. For Hawaii and Montana employees who are pregnant and
seeking either leave or a workplace accommodation, please complete only questions 1, 2, 10, and 11.
IMPORTANT: If employee is requesting a medical exemption to a COVID-19 vaccine with no other
accommodations, only provide information that is related to the impairment or condition that precludes the
employee from receiving a COVID-19 vaccine.
IMPORTANT NOTICE REGARDING GINA
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other
entities covered by GINA Title II from requesting or requiring genetic information of employees
or their family members. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information.
“Genetic information,” as defined by GINA, includes an individual’s family medical history, the
results of an individual’s or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual’s family member or an embryo lawfully held by an
individual or family member receiving assistive reproductive services.
1. Please confirm whether you have examined the employee and are familiar with the employee’s medical
history:
Yes No
2. Will this employee have a need for any of the following? Check ALL that apply:
Restrictions Limitations Accommodations
Leave of absence COVID-19 vaccine exemption None of the above
LeaveID: 265292148817
Fax: 303-404-6617
If None of the above, please state the employee’s unrestricted return to work date:
3. Existence of impairment.
a. Does the employee have a physical or mental impairment(s)? Yes No
b. Is the impairment related to pregnancy or childbirth? Yes No
i. If yes, are there complications?
ii. If yes, describe the complications (Do not answer without patient consent in CA, ME,
or RI):_______________________________________________________________
____________________________________________________________________
iii. Estimated Delivery Date: __/__/__ Actual Delivery Date: __/__/__
4. Please list impairment(s) (Note: Some state laws may prohibit providing a diagnosis):
_____________________________________________________________________________________
Note: A physical or mental impairment under the ADA is:
• Any physiological disorder, condition, cosmetic disfigurement, or anatomical loss affecting one or
more body systems, such as neurological, musculoskeletal, special sense organs, respiratory
(including speech organs), cardiovascular, reproductive, digestive, genitourinary, immune,
circulatory, hemic, lymphatic, skin, and endocrine; or
• Any mental or psychological disorder, such as an intellectual disability, organic brain syndrome,
emotional or mental illness, and specific learning disabilities.
*The definition of an impairment may differ slightly under state law.
5. COVID-19 Vaccine Exemption. Does the employee’s impairment(s) prevent the employee from receiving a
COVID-19 vaccination? Yes No
If Yes, is the exemption:
Temporary, ending on : / /
Permanent
6. Limitations on major life activities. Does the employee’s impairment substantially limit one or more major life
activities? Yes No
Note: Whether an impairment substantially limits a major life activity of the employee is determined:
• As compared to most people in the general population;
• Without regard to the ameliorative effects of mitigating measures such as medication, medical
supplies or equipment, prosthetics, hearing devices, mobility devices, assistive technology,
reasonable accommodations, auxiliary aids, or behavioral or adaptive neurological
modifications; and
• When the impairment is active, for impairments that are episodic or in remission.
7. Limitations on major life activities (cont.). Which major life activity(ies) is/are substantially limited?
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Dept 00058 LeaveID: 265292148817
P.O. Box 299093
Fax: 303-404-6617
LewisvilleTX 75029-9093
Major life activities – general life activities:
□ Bending □ Interacting with others □ Reaching □ Standing
□ Breathing □ Learning □ Reading □ Thinking
□ Caring for self □ Lifting □ Seeing □ Walking
□ Concentrating □ Performing manual tasks □ Sitting □ Working
□ Eating □ Sleeping □ Other(s) (describe)
□ Hearing □ Speaking
Major life activities – operation of major bodily functions:
□ Bladder □ Digestive □ Lymphatic □ Reproductive
□ Bowels □ Endocrine □ Musculoskeletal □ Respiratory
□ Brain □ Genitourinary □ Neurological □ Sensory organs & skin
□ Cardiovascular □ Hemic □ Normal cell growth □ Other(s) (describe)
□ Circulatory □ Immune □ Operation of an
organ
8. Commencement of impairment(s). For the impairments identified above, when did the employee’s
impairment(s) commence? If there is more than one impairment, please specify the start date for each:
9. Performance of essential job functions. Does the employee’s impairment(s) limit his/her ability to perform
the essential functions of the employee’s position (as defined in the job description) without any
accommodation? Yes No
If the answer is yes, please:
a. Identify which essential function(s) the employee is unable to perform without an accommodation:
b. Describe the manner in which the employee’s ability to perform each essential function is limited:
10. Accommodation(s).
a. Please describe the workplace accommodation(s) that you are recommending for the employee (for leave
as an accommodation, please also answer question 11):
Note: Reasonable accommodations may include such things as a modified work schedule, provision of special
equipment, workplace accessibility modifications, shifting of non-essential duties of the employee’s position,
and extended leave of absence to allow time for recovery, therapy, training, or other disability-related needs.
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Dept 00058 LeaveID: 265292148817
P.O. Box 299093 Fax: 303-404-6617
Lewisville TX75029-9093
Reasonable accommodations related to the COVID-19 vaccine might include an exemption to receiving the
vaccine and/or such things as regular COVID-19 testing, required masking, socially distanced workspace,
modified work schedule, etc.
b. If the accommodation is to assist with a physical limitation, please complete the attached Appendix A,
Physical Capacity Assessment form. (not required if requesting only a COVID-19 vaccine exemption)
c. How will the accommodation(s) assist the employee in performing the essential job functions?
d. Duration. For how long do you anticipate the employee will need the identified accommodation(s)?
Start date: / / End date: / / or permanent
For multiple accommodations, please list each accommodation’s duration separately: ____________
___________________________________________________________________________________
NOTE: You must provide your best medical judgment, based on current information, as to the length of time
the employee will need an accommodation to perform his/her essential job functions.
11. Is this employee specifically requesting a leave of absence as an accommodation? Yes No
Note: If Yes, answer part the remaining sections of this question (a, b, and c) below. If No, skip the rest of
Question 11 and proceed to Question 12.
a. Will leave assist the employee in eventually returning to work? Yes No
b. How will leave assist the employee in returning to work?
c. Duration and Type of Leave. Please indicate the type of leave needed and complete the duration details
for that section.
CONTINUOUS LEAVE:
If the employee requires leave for a single continuous period of time, please complete this section.
Start date of leave: / / End date of leave: / /
IMPORTANT: An end date must be provided. “To be determined,” “unknown,” or “indefinite” is not adequate. If you
are unsure of the end date, provide your best estimate. End dates can be changed, if necessary, with updated
documentation.
REDUCED LEAVE:
If it is medically necessary due to the patient’s condition for the employee to reduce the number of
hours of the employee’s daily or weekly work schedule, please complete this section.
• Start date of leave: / / End date of leave: / /
• Reduced Schedule: ___ days per week ___ hours per day and/or week
INTERMITTENT LEAVE:
If it is medically necessary due to the patient’s condition, for the employee to take leave in intermittent
periods of time, please complete this section.
ii. Incapacity (Estimated Episodic Flare-Ups):
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Dept 00058 LeaveID: 265292148817
P.O. Box 299093
LewisvilleTX 75029-9093 Fax: 303-404-6617
• Start date: / / End date: / /
• Episodes will be times every days (use 7, 30, 365). Each episode of incapacity
may last up to hours or days. (e.g., 2 times every 30 days, lasting up to 1 day)
iii. Office Visits and/or Treatment Schedule (Excluding Incapacity Time):
• Start date: / / End date: / /
• Office visits and/or treatments will be time(s) every days (use 7, 30, 365).
• Each office visit and/or treatment will last approximately hours. (e.g., 2 times
every 30 days, lasting up to 2 hours)
NOTE: You must provide your best medical judgment, based on current information, as to the length of time the
employee will need an accommodation to perform his/her essential job functions.
12. Additional information. Are you aware of any other information that should be considered in assessing
whether the employee can perform the essential job functions with or without accommodation?
Yes No
If yes, please describe:
Provider Name (print):
Provider Signature:
Provider Practice/Specialty:
Provider Phone Number:
Provider Fax Number: _________
Provider Address:
Provider Email: ___________________________________________________________
Date:
Alight
Dept 00058 LeaveID: 265292148817
P.O. Box 299093
Fax: 303-404-6617
LewisvilleTX 75029-9093
NFII|1|265292148817
