this form, and my health care providers agents and associates, to release medical
information about me to Amazon, as needed to enable Amazon to evaluate whether and
how my medical condition impacts my ability to perform my job duties and to further
evaluate accommodations that may assist me in performing my job. This
authorization covers subsequent requests by Amazon for clarifying and obtaining
additional information relevant to these subjects. I understand this authorization
may expire under the laws of some states after I sign it, but I agree to extend my
authorization as needed for these purposes.
__________________________________________________________________________
_______________________
Signature of Employee or Guardian Relationship to Employee (if signed by guardian)
Date Signed
To be completed by Healthcare Provider
Healthcare Provider: The intent of this form is to identify restrictions,
limitations, and/or qualifying disabilities to be considered for work
accommodations. This form is intended to assist with evaluating accommodations for
medical restrictions and limitations not related to workplace injuries or
illnesses.
SECTION I: PATIENT/EMPLOYEE RETURN TO WORK STATUS - This section is used to
determine disability status for evaluating accommodations only.
Please select current status for employee:
Currently able to return to work with no restrictions
Currently able to return with restrictions as listed in Section II.
Duration of restrictions: from: ___________ to: ____________
(Completing above section indicates a release to full duty on the day after the
noted “to” date)
Duration of restrictions unknown at this time. However, I am expecting
significant clinical improvement in the following time frame which should allow me
to develop a release date and plan: ⬜ in the next office visit ⬜ in the next 4
weeks ⬜ in the next 8 weeks ⬜ Other, describe: _______________________________
Currently unable to return to work
Employee will be able to return to work on this date: *_______________
Unknown when employee will be able to return to work. However, I am expecting
significant clinical improvement in the following time frame which should allow me
to develop a release date and plan: ⬜ in the next office visit ⬜ in the next 4
weeks ⬜ in the next 8 weeks ⬜ Other, describe:
* If employee may return with restrictions, please describe nature and duration
of restrictions, to the extent known by completing Section II below. (Information
can be revised/updated at any time.)
Does the employee have a condition or impairment that limits his/her ability to
perform his or her job duties?
No
Yes. What major life activities or major bodily functions are affected? Check all
that apply:
MAJOR LIFE ACTIVITIES
Caring for Self
Sleeping
Speaking
Thinking
Communicating
Concentrating
Walking
Breathing
Performing manual tasks
Bending
Lifting
Seeing
Standing
Hearing
Learning
Working
Reading
Eating
Other (list or describe):
MAJOR BODILY FUNCTIONS:
Immune System
Bowel
Brain
Endocrine
Normal Cell Growth
Bladder
Neurologic
Reproductive Functions
Digestive
Respiratory
Circulatory
Other (list or describe):
Describe impact of condition on patient’s daily life activities:
SECTION II: PHYSICAL RESTRICTIONS RELATED TO EMPLOYEE’S JOB FUNCTIONS
Please note any physical and/or psychological limitations or restrictions that may
interfere with performance of job duties and/or may require workplace
modifications. If the employee’s limitations or restrictions do not affect the
employee’s ability to perform a particular job task, do not provide a response.
Date of evaluation: _____________________
Job Task
(Please indicate if Left, Right, or Both sides)
Time
Limitation Period
Please indicate the maximum amount of time in hours the
patient/employee is allowed to perform each task.
Up to
5 lbs.
Up to
10 lbs.
Up to
15 lbs.
Up to
20 lbs.
Up to
30 lbs.
Up to
40 lbs.
Up to
50 lbs.
Start Date
End Date
Permanent Limitation
Lift/Carry: (Left, Right, Both)
Push/Pull: (Left, Right, Both)
Job Task
Time
Limitation Period
Please indicate the maximum amount of time in hours the
patient/employee is allowed to perform each task.
Start Date
End Date
Permanent
Limitation
Repetitive Motion of Hands: (Left, Right, Both)
Simple Hand Grip (<15 lbs.): (Left, Right, Both)
Forceful Hand Grip (>15 lbs.): (Left, Right, Both)
Overhead Reach: (Left, Right, Both)
At Shoulder Reach: (Left, Right, Both)
Below Shoulder Reach: (Left, Right, Both)
Head/Neck Rotation (> 20°): (Left, Right, Both)
Bend/Pivot
Kneel
Crawl
Squat
Sit
Stand
Walk
Climb Stairs (5 or more steps)
Climb Step Stool (4 or less steps)
Amazon considers all available accommodations for employees who need them. This
may include alternative functions or positions for employees who cannot be
accommodated in their current roles. Please answer the following questions to help
us ensure that appropriate accommodations are considered. Include only information
that is relevant to your patient’s request for an accommodation at Amazon.
1
Does the employee require a modification related to hours of work?
If YES, can the employee work more than 40 hours within a week in their current
role?
YES
NO
If modification required, please identify the maximum number of hours the employee
can work: hours/day hours/week
Does Not Apply:
Does the employee require additional breaks, a modified schedule, or intermittent
time off? If so, please identify the frequency and duration of the time away
requirements:
_____ number of absences/breaks per ● day ● week ● month ● year
_____ number of minutes, hours or days (circle one) per absence/break
Describe the modified schedule (if any):
Does Not Apply:
3
Does the employee have any other relevant current limitations or restrictions not
listed elsewhere (e.g. physical, sensory, psychiatric) that may interfere with
performance of job duties and/or require job modifications? If so, please describe
the relevant limitations or restrictions.
Does Not Apply:
4
Does the employee have any current limitations or restrictions that would inhibit
the employee’s ability to perform Safety Sensitive functions, such as operating a
delivery van, forklift, reach truck, scissor lift, or truck, or working from
heights at the patient’s current worksite? if so, please describe the relevant
limitations or restrictions.
Does Not Apply:
5
Does the employee have any current limitations or restrictions that impair the
employee’s ability to wear safety shoes, gloves, or other personal protective
equipment? if so, please describe the relevant limitations or restrictions.
Does Not Apply:
6
Does the employee have any current limitations or restrictions that impact the
employee’s ability to work in a freezer? If the employee requires accommodations to
work in a freezer, please explain:
Does Not Apply:
7
Does the employee require any accessible materials, equipment, or therapeutic
devices to perform work at their current worksite?
If yes, please explain/describe:
Does Not Apply:
8
Additional Notes (relevant to accommodations needed at work):
SECTION III: HEALTHCARE PROVIDER SIGNATURE AND CONTACT INFORMATION
HEALTHCARE PROVIDER NAME/TITLEHEALTHCARE PROVIDER SIGNATURE:DATE