WORKPLACE ACCOMMODATION LETTER

[Practice name]
[Address]
[Phone and email]

Date: [Date you write the letter]

To: [Employer, human resources, or occupational health contact]
Re: [Patient's full name]
Date of birth: [Date]
Job title: [Job title]
Reference: [Request or file number, if the employer gave one]

[Patient name] asked me for this letter and agreed to the information in it.

MY ROLE
I am [patient name]'s [family physician, psychologist, or other role]. I have treated them since [month and year] and last assessed them on [date], [in person, by video, or by phone].

HEALTH CONDITION
[Patient name] has a [physical or mental health condition, or its general type] that is [ongoing, temporary, or episodic]. It limits [the activities it limits, e.g. standing, sleeping, concentrating].
Diagnosis: [Only with the patient's consent; otherwise delete this line]

FUNCTIONAL LIMITATIONS
[What they can't do at work, or can do only with difficulty, in numbers where you can, e.g. can't sit for more than 30 minutes at a time]
Effect on the job: [The tasks or conditions it makes harder, e.g. the commute, an early start, standing at a counter]

ACCOMMODATION RECOMMENDED
[The change, and how much, e.g. work from home 3 days a week, a sit-stand desk, a 10 a.m. start, time off for weekly appointments]
How it helps: [One line linking the change to the limitation]
Other options that may also work: [Alternatives, or none known]

DURATION AND REVIEW
Expected to be needed: [Weeks or months, long term, or not yet known]
Review date: [When I will reassess and update this letter]

EMPLOYER'S QUESTIONS
[Each question the employer asked about this condition and the job, with a short answer; otherwise delete this section]

I have shared only the information needed for this request. For questions about this letter, call [practice phone].

[Your name, credentials]
[License or registration number]
[Signature]