SOP 104.21-att-2: ADA Physician's Statement

104.21
Attachment 2

Page 1 of 2

4/25/17

GEORGIA DEPARTMENT OF CORRECTIONS

ADA PHYSICIAN’S STATEMENT

|Employee’s Name|Job Title:|ID:|
|---|---|---|
|Physician’s Name|Address:|Phone#:

|

INSTRUCTIONS : Please answer all of the questions below. We need your complete medical
opinion, so please feel free to include a more detailed narrative response to all questions, if
needed, to answer more thoroughly. When answering these questions, please do not take into
consideration corrective effects of mitigating measures, such as, medication, medical supplies,
equipment, or appliances, low-vision devices (which do not include ordinary eyeglasses or
contact lenses), prosthetics including limbs and devices, hearing aids and cochlear implants or
other implantable hearing mobility devices, or oxygen therapy equipment and supplies; use of
assistive technology; reasonable accommodations or auxiliary aids or services; or learned
behavioral or adaptive neurological modifications.

|( )
Yes|( )
No|Does the employee have a physical or mental impairment? If “yes”, type of
impairment:|
|---|---|---|
|( )
Yes|( )
No|Does the impairment substantially limit any major life activities? If “yes”, which major
life activity or activities are limited?




For each major life activity that is limited by the impairment, please describe how the
employee is restricted as to the condition, manner, or duration under which that activity
can be performed, as compared to the way in which an average person in the general
population can perform that activity:




What is the expected duration of the impairment?

|

Record Retention: Retain permanently in the employee’s local medical file.

|Col1|Col2|104.21 Attachment 2 Page 2 of 2 4/25/17|
|---|---|---|
|( )
Yes|( )
No|Can the employee perform all job functions in the attached description/performance
plan? If “no”, which job functions cannot be performed, and why not?




Please describe any reasonable accommodations that would allow this employee to be
able to perform those job functions.




If medical leave is one of the possible accommodations listed above, please provide
estimated duration for the leave:


|
|( )
Yes|( )
No|Would performing any of those job functions listed result in direct safety or health
threat to this employee or others (co-workers, members of the general public, etc…) If
“yes”, please describe which job function(s) would pose such as threat.




Describe the direct safety or health threat posed:




Describe any reasonable accommodations that would eliminate the direct safety or
health threat, or reduce it to an acceptable level:




|

Signature of Attending Physician: _________________________________ Date: ____________

Record Retention: Retain permanently in the employee’s local medical file.