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DHR EO 014B <br />(July 2018) <br />County of Hawai'i <br />Department of <br />Confidential Re ...................... . ..... . --­ . ....... .. .................. quest for Medical Information - Job Applicant <br />(Date) <br />Medical Professional Name <br />Street Address <br />City, State, Zip Code <br />Dear <br />Medical Professional Name: <br />Re: <br />Job Applicant <br />quest for Accommodation <br />I recently received information that the individual named above has a medical <br />condition which may impact her/his ability to <br />o apply for a position with the County of Hawaii. <br />I am requesting additional information to assist me in determining whether this <br />individual needs an accommodation to better access our job application <br />process. <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 a brief description of our job application process. <br />Sincerely, <br />(Name) <br />(Title) <br />