Attachment IV Questions for Healthcare Provider.pdf

Questions for Healthcare Provider

The Department of the Navy (DON) requires additional information to determine whether EMPLOYEE'S NAME is a qualified individual with a disability, and therefore entitled to a reasonable accommodation, unless it creates an undue hardship. To properly address the request for a reasonable accommodation, the DON requests that this document be completed in narrative form by a healthcare professional, or to have all of the below questions addressed on the healthcare professional’s letterhead.

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 an individual or family member of the individual, except as specifically allowed by this law.

Therefore, please do 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.

To assist in responding to the questions below, the essential functions of EMPLOYEE'S NAME position as a POSTION TITLE are as follows:

ESSENTIAL FUNCTION #1:

JUSTIFICATION:

ESSENTIAL FUNCTION #2:

JUSTIFICATION:

ESSENTIAL FUNCTION #3:

JUSTIFICATION:

ESSENTIAL FUNCTION #4:

JUSTIFICATION:

ESSENTIAL FUNCTION #5:

JUSTIFICATION:

1. What is the nature, severity, and duration of employee's medical condition for which he/she is requesting a reasonable accommodation?

a. Nature

b. Severity- provide the severity for each medical condition

c. Duration- how long have they had this condition

2. Provide an estimate of the expected date of full or partial recovery.

3. Can you explain the impact of employee's medical condition on his/her activities on the job and off the job (if relevant to the request)? Describe how the medical condition impacts his/her ability to perform the job duties in the workplace or enjoy equal benefits or privileges of employment.

Questions for Healthcare Provider

4. What functional limitations does employee's medical condition produce that may impact his/ her ability to perform the duties of his/her position as described in the essential functions document? Describe in detail and provide current coping/management/treatment plans in place to support the employee.

5. Please identify the trigger(s) that may result in a need for a reasonable accommodation. If trigger(s) exist, please explain what the agency can do or provide the employee to reduce or eliminate the occurrence of the identified trigger(s) as it relates to performing the essential functions.

6. Employee stated disability name impacts his/her at work. Please provide information on the limitation and the resultant necessity for accommodations. Please provide more specificity and parameters (i.e. needed amount of time, frequency, equipment that may be needed, suggested alternative accommodations, etc.) for the requested accommodation. If there are multiple reasonable accommodations that may be effective, please provide information on all possible accommodation options.

Printed name of Healthcare Professional Signature of Healthcare Professional Date

Contact information of Healthcare

Professional Practice:

Phone number:

Email:

7. On the basis of your medical expertise and knowledge of employee's position from the information provided, please provide an assessment of his/her ability to successfully perform the essential elements of the position, with or without an accommodation.

Supplemental Questions for Healthcare Provider

The Department of the Navy (DON) requires additional information to determine whether EMPLOYEE'S NAME is a qualified individual with a disability, and therefore entitled to a reasonable accommodation, unless it creates an undue hardship. To properly address the request for a reasonable accommodation, the DON requests that this document be completed in narrative form by a healthcare professional, or to have all of the below questions addressed on the healthcare professional’s letterhead. 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 an individual or family member of the individual, except as specifically allowed by this law. Therefore, please do 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. To assist in responding to the questions below, the essential functions of EMPLOYEE'S NAME’s position as a POSITION TITLE Contract Specialist are as follows:

Sample questions starters:

• If the initial description of the medical condition is vague: "In the response to question 1a, the healthcare professional described the condition as [Doctor's Description]. Could you please provide a more specific diagnosis or a more detailed explanation of the underlying medical issue?"

• If the severity/impact is unclear: "The healthcare professional rated the severity of the condition as [Doctor's Rating] in question 1b. Can you provide specific examples of how this level of severity manifests in terms of functional limitations that might affect job performance?"

• If the impact on specific job duties isn't clear: "In question 3, the healthcare professional mentioned the condition affects [Employee Name]'s ability to [General Activity]. Can you specify which essential functions of the job (referencing the attached job description) are most directly impacted by this?"

II. Specificity of Functional Limitations:

• If the functional limitations are too broad: "In question 4, the healthcare professional listed [Functional Limitation]. Can you provide more details about the specific types of tasks or activities that are most difficult for [Employee Name] due to this limitation? For example, if the limitation is 'difficulty concentrating,' what specific types of tasks requiring concentration are most challenging?"

• If the connection between the medical condition and the functional limitation isn't clear: "The healthcare professional mentioned [Functional Limitation] in question 4. Can you explain the medical basis for this limitation? How does the underlying medical condition directly cause this specific functional limitation?"

III. Accommodation Details and Feasibility:

• If the requested accommodation is unclear or lacks detail: "Regarding the requested accommodation of [Requested Accommodation], can you provide more specific parameters? For example, if the request is for 'frequent breaks,' how frequent should these breaks be, how long should they last, and what is the medical justification for these specific parameters?"

• If the requested accommodation seems overly burdensome: "We understand the need for [Requested Accommodation]. However, implementing this accommodation as described may present significant operational challenges. Are there any alternative accommodations that might be equally effective in addressing [Employee Name]'s functional limitations?"

• If you have concerns about the effectiveness of the proposed accommodation:

"Based on your understanding of the job requirements and [Employee Name]'s limitations, do you believe that the proposed accommodation of [Proposed Accommodation] will fully enable them to perform the essential functions of their position? If not, what additional accommodations might be necessary?"

• If the doctor suggested an accommodation you're unfamiliar with: "The healthcare professional suggested [Doctor's Suggested Accommodation]. Can you provide more information about this accommodation, including how it works and how it addresses [Employee Name]'s specific functional limitations?"

IV. Triggers and Mitigation Strategies:

• If the doctor identified triggers, but the mitigation strategies are vague: "The healthcare professional identified [Trigger] as a factor that exacerbates [Employee Name]'s condition. You suggested [Mitigation Strategy]. Can you provide more specific recommendations on how we can implement this strategy effectively? For example, if the trigger is 'stress,' what specific stress-reduction techniques would you recommend?"

• If the doctor didn't identify any triggers, but you suspect there might be some:

"Are there any specific workplace conditions or environmental factors that you believe could potentially worsen [Employee Name]'s condition and increase their need for accommodation? This could include factors like noise levels, lighting, temperature, or air quality."

V. Ability to Perform Essential Functions (Overall Assessment):

• If the doctor's assessment of the employee's ability to perform essential functions is unclear or qualified: "In question 7, the healthcare professional stated that [Employee Name] should be able to perform the essential functions with [Certain Accommodations]. Are there any essential functions that you believe [Employee Name] may still have difficulty performing, even with these accommodations in place? If so, what further accommodations might be necessary?"

• If you are considering denying the accommodation request based on undue hardship: "We are exploring the feasibility of providing the requested accommodations. Are there any less costly or less disruptive alternatives that would still be effective in enabling [Employee Name] to perform the essential functions of their position?"

Commute Triggers

• "We understand that [Employee Name]'s commute to the office may be a trigger for [Specific Symptoms/Condition]. While driving is not an essential function of their position, we want to provide reasonable accommodations to support them upon arrival at the workplace.

• Knowing that the commute may exacerbate [Specific Symptoms/Condition], what specific in-office accommodations (e.g., adjustments to work schedule, access to a quiet space, modified tasks upon arrival, etc.) would be most effective in helping [Employee Name] manage the effects of their commute and perform the essential functions of their job effectively once they are at work? Please provide specific details regarding the nature of the accommodation, the duration for which it may be needed upon arrival, and the medical rationale for your recommendation."