Physician Questionnaire
Your patient, ______, is an employee of the County of ______. We wish to return ______to work. We have enclosed a job description and essential functions list. In order to expedite the processing of your patient’s request, please be as complete and specific as possible. We are requesting you to provide feedback to the following questions based on your medical expertise.
PLEASE BE ADVISED THAT THIS INFORMATION WILL BE USED TO ASSIST THE COUNTY IN THE DECISION RELATED TO THE EMPLOYEE’S ABILITY TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB. THIS INFORMATION IS JUST A PART OF WHAT IS CONSIDERED.
What we require is for you to review the essential functions provided herein and to answer the following questions.
1. Please review the essential functions of the patient’s job requirements that are attached hereto. Is the employee able to perform the essential functions of this position with or without reasonable accommodation? _____ Yes _____No
If yes please go to question No. 2.
If no:
a. please identify the functions of your patient’s job he or she is unable to perform.
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b. how long will the employee be unable to perform these job duties?
___ a month ______3 months ______6 months _____ 1 year
_____ unknown _____ permanently
2. In performing the essential functions of this job, in your opinion, would the employee pose a significant risk of substantial harm to the health of safety of the employee or others, that cannot be eliminated by an accommodation. ______Yes ______No
If so, please state why
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The individual named above is my patient. The information provided here is based upon my knowledge of the patient and the patient’s physical or mental impairment.
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Signature of Caregiver Date
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Printed Name
______
Type of Practice
______
Contact address and phone
PLEASE RETURN TO: (employee or employer please fill out name and address below before providing this to your care provider)
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