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Confidential Request for Medical Information - Employee - DHR EO 14A <br />Page 2 of 4 <br />Under the Americans with Disabilities Act, an individual has a disability if the <br />individual has an impairment that substantially limits one or more major life <br />activities. <br />Does <br />(name) <br />o Yes <br />have a physical or mental impairment? <br />What is the impairment? <br />o No <br />Is the impairment long-term or permanent? c) Yes o No <br />If it is not permanent, how long will the impairment last? <br />Is the impairment chronic or episodic? <br />(Please circle the word that applies). <br />Does the impairment limit a major life activity? o Yes o No <br />Please review the list of major life activities on the next page and check all that <br />are limited: <br />Major Life Activities <br />oCaring for oneself <br />oSitting <br />oWalking <br />olnteracting <br />oReaching <br />oConcentrating <br />oPerforming Manual <br />oThinking <br />oReading <br />oTasks <br />oSleeping <br />oReproduction <br />oLearning <br />oEating <br />oSpeaking <br />oHearing <br />oWorking <br />oSeeing <br />oLifting <br />oStanding <br />oOther: <br />oBreathing <br />(specify) <br />Please indicate if the impairment substantially limits any of the following bodily <br />systems: <br />olmmune oDigestive oBladder <br />oHemic oBowel oEndocrine <br />oNeurological o Normal Cell Growth <br />oMusculoskeletal <br />Does the impairment substantially limit one or more major life activities? <br />o Yes 0 No <br />