EOA - Medical Information Request Form - Medical Provider

for Vanderbilt Employees

To Vanderbilt Employee:

To initiate a request for a reasonable accommodation, an employee must:
• Submit the completed Reasonable Accommodation Request form and the Medical Information Request form to Equal Opportunity and Access (EOA).
• The Medical Information Request form is to be completed by the employee's physician or care provider. Employees are
to complete Section I below, provide a copy of their job description to their medical provider and have the medical
provider complete Section II.
• Completed forms are to be returned to:

Equal Opportunity and Access (EOA)
Loews, Suite 780
2100 West End Avenue
Nashville, TN 37203
or fax to (615) 343-4709
For questions, please call (615) 343-9336.
Section I: To be completed by employee:
Employee name Employee name First Last
Job Title
Department
Supervisor Supervisor First Last
Release of Information

I hereby authorize the release of the following information to Vanderbilt for the purpose of determining the availability of reasonable
workplace accommodations. I further authorize Vanderbilt to seek clarification of this documentation if necessary by contacting my
physician or care provider.
Employee signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Section II: To be completed by the physician or care provider:

To Physician or Care Provider:

To initiate a request for reasonable accommodations, employees must provide current documentation of a disability. As the
employee's physician or care provider, you are asked to fully complete all sections of this form. Additional information can be
attached if necessary. Note: Federal and state law define a disability as a physical or mental impairment that substantially limits one or more major life activities, an individual having a record of such an impairment, or an individual being regarded as having such an impairment.

To complete this form (see attached, page 2, section 2), you should review the employee's job functions and other information relevant to the employee's job at Vanderbilt. If those materials have not been provided, please contact the employee and let him or her know you cannot complete this form without those materials.

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. 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. Thank you for your assistance.
1. Please identify the employee's physical or mental impairment:
2. Please describe the effects or limitations (e.g., long-term, permanent, recent, short-term).
3. Please describe the effects or limitations this impairment has on the employee's activities, if any:
4. By reviewing the attached information concerning the employee's job duties, please describe the effect or limitations the impairment has on the employee's ability to perform the job duties, if any:
5. Are there any activities or situations that should be avoided or that would present a health or safety risk to the employee or others due to the impairment?
6. Please offer any suggested accommodations that might enable the employee to perform his or her job duties. How many suggestions do you have?
Suggestion 1 - Please list request and duration.
Suggestion 2 - Please list request and duration.
Suggestion 3 - Please list request and duration.
Thank you for your assistance in providing this information so that we may assess the employee's request. Please sign below.
Signature of physician or care provider

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Provider name (printed) Provider name (printed) First Last
Telephone # Telephone # - ### - ### ####

EOA - Medical Information Request Form - Medical Provider

EOA - Medical Information Request Form - Medical Provider

To Vanderbilt Employee:

Section I: To be completed by employee:

Release of Information

Section II: To be completed by the physician or care provider:

Thank you for your assistance in providing this information so that we may assess the employee's request. Please sign below.