HEALTH CARE PROVIDER FORMCWU Employee(Health Care Provider Completes This Section)
Your patient is requesting an accommodation regarding his/her employment. The information you provide is critical to our ability to determine the appropriate services and/or accommodations, if any, for this employee. Please be thorough in your evaluation as you complete the sections as it will help us assist your patient. Your timely completion of this form is essential to our ability to respond to your patient’s accommodation request.
Note: If you would rather provide your patient's medical information in traditional paper form, please feel free to fill out our Health Care Provider Statement Form (pdf). You may then email it as an attachment, fax it, or mail it to us. Our contact information can be found on our Home Page.
Please check all "major life activities" in which your patient experiences significant functional limitations due to a disability or disabilities:
Please review the enclosed position description and list your recommendations for accommodations for the work environment. Please provide a rationale for any recommendation made utilizing data from objective measures. Please list or attach under separate cover.
Please provide the following information about the Medical Professional completing this form:
Note to Medical Professional: By providing the Certifier information above, you are confirming that the information contained in this document is true and accurate to the best of your knowledge.
Clicking the "submit" button will send this form electronically to:
Human Resources/Disability ServicesCentral Washington UniversityEllensburg, WA