State Department employees requesting a reasonable accommodation give this questionnaire, with a Work Requirements Statement, to their medical provider. The provider describes the condition, the work activities it limits and any accommodation needed, and Department medical professionals and the Disability and Reasonable Accommodation Division (HR/OAA/DRAD) review it to decide the request.
The employee signs the release, adds contact details and writes a separate statement of the limitations and accommodation requested. The medical provider completes the 'For the Medical Provider' pages (3 to 5) and the Medical Provider Information block with signature or electronic certification checkbox.
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Medical Questionnaire for Assessment of Disability/Reasonable Accommodation
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Yes. The form says the provider may respond on official letterhead with name, address and telephone number, as long as the response covers the same questions: the condition, the limitations, review of the Work Requirements Statement, the accommodation and its expected duration. The provider still signs and dates the response.
State Department medical professionals and select staff from HR/OAA/DRAD who routinely review such information. The Privacy Act statement says information collected on the form will not be shared outside the Department of State, and that the review follows the Rehabilitation Act and the Americans with Disabilities Act as amended.
It describes the employee's job requirements. The employee submits it to the provider with DS-6546 so recommendations are made with full knowledge of the work. The provider reviews it before specifying any accommodation and can list it in the attachments line of the provider information block.