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DHR EO 14A <br />(July 2018) <br />County of Hawaii <br />Department of <br />Confidential Request for Medical Information - Employee <br />(Date) <br />Medical Professional Name <br />Street Address <br />City, State, Zip Code <br />Dear <br />Medical Professional Name: <br />Re: Request for Accommodation <br />Employee Name <br />I recently received information that the individual named above has a medical <br />condition which may impact her/his ability to perform essential job functions. <br />I am requesting additional information to assist me in determining whether this <br />employee needs an accommodation to perform essential job functions. <br />Please complete this form and return to me by . If you have any <br />(date) <br />questions about this inquiry, please contact me. My telephone number is <br />Enclosed please find a signed copy of an Authorization to Release Medical <br />Information and job description with essential functions highlighted. <br />Sincerely, <br />(Name) <br />(Title) <br />