Attachment 3 - Medical Review Form


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Attachment 3 - Medical Review Form (pdf)


Text Version of Form


AmeriCorps Illinois

Illinois AmeriCorps Disability Outreach Project
MEDICAL REVIEW FORM

The Serve Illinois Commission is requesting disclosure of information that is necessary to assist in evaluating a reasonable accommodation request. Disclosure of this information is VOLUNTARY.

  • Member/ Applicant Name:
  • Date of Birth:
  • Home Address :
  • State:
  • Zip:
  • Social Security Number:
  • Program Name:
  • Contact Name:
  • Address:
  • Member/ Applicant's disability:
    (including a physical or mental impairment that substantially limits one or more major life activities, which include such things as caring for oneself, performing manual tasks, walking, sitting, standing, lifting, reaching, seeing, hearing, breathing, learning, and working)
  • Major life limitation (s):
  • What are the specific essential job functions this person cannot perform without a reasonable accommodation due to the disability?
  • What type of reasonable accommodation do you suggest for the member/ applicant?
  • What, if any, alternative accommodation(s)?
  • Recommended duration of reasonable accommodation:
  • Additional information to support need for reasonable accommodation:
  • Physician's printed name:
  • Degree:
  • License Number:
  • Address:
  • Telephone Number:
  • Physician's signature:
  • Date:

*Members/applicants are responsible for having this form completed by Physician and forwarded to your Program Director.