ADA Medical Assessment Form

Forms can be mailed to: Hartford Leave Management

P.O Box 14869
Lexington, KY 40512-4869
Or faxed to: Toll Free Fax Number: (833) 357-5153

This form must be returned no later than:

Employee’s Name: Last 4 digits of Social Security Number:

Leave ID: Date of Birth:

Employer’s Name:

Today’s Date:

The above employee has requested an accommodation under the Americans with Disabilities
Act Amendments Act (ADAAA), as amended, to enable the employee to perform the essential
functions of his/her position. The information requested on this form will assist in making a
determination regarding the employee’s request.

INSTRUCTIONS: The following form must be completed in detail and signed by the employee’s
medical provider. Please attach additional pages or records as needed. Do not provide
information not related to the employee’s ability to perform his/her job duties. Example:
Do not identify an impairment if it does not have an impact on employee’s ability to
perform his/her job duties.

IMPORTANT NOTICE REGARDING GINA

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law To comply with this law, we are asking that you not provide any
genetic information when responding to this request for medical information. “Genetic information” as defined
by GINA, includes the manifestation of disease or disorder in family members of the individual, an individual’s
family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual
or an individual’s family member sought or received genetic services and genetic information of a fetus carried
by an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting companies Hartford Life and Accident Insurance Company
and Hartford Fire Insurance Company. Home Office is Hartford, CT. The Hartford is the administrator for certain group benefits business written by Aetna Life
Insurance Company and Talcott Resolution Life Insurance Company (formerly known as Hartford Life Insurance Company). The Hartford also provides administrative
and claim services for employer leave of absence programs and self-funded disability benefit plans.

LC-7630-5 Page 1 of 5 11/2020

 1. Please confirm you have examined the employee and are familiar with the employee’s medical
history. Yes No

2. Please confirm you have reviewed the job description or equivalent for the employee.
Yes No

3. Is the employee released to return to work full time, full duty without the need for restrictions,
limitations, or accommodations? Yes No

If yes, please state the employee’s full, unrestricted return to work date:

IF NO, PLEASE COMPLETE THIS FORM.

4. When can the employee return to work with restrictions or an accommodation? [Additional
questions regarding restrictions or accommodations below].

5. Existence of impairment. Does the employee have a physical or mental impairment(s)?

No Yes Please list impairment(s):

Note: A physical or mental impairment under the ADA is:

 Any physiological disorder, condition, cosmetic disfigurement, or anatomical loss affecting one or
more of the following body systems: Neurological, musculoskeletal, special sense organs,
respiratory (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic
and lymphatic, skin, and endocrine; or

 Any mental or psychological disorder, such as an intellectual disability, organic brain syndrome,
emotional or mental illness, and specific learning disabilities.

 The disorder or condition is considered:

o In its active state, even if presently in remission. (Examples: epilepsy, MS, asthma, cancer,
bipolar disorder.)
o Without regard to the effects of mitigating measures such as prostheses, medication, etc.,
except ordinary eyeglasses.
o With consideration of the negative effects of treatment such as medication or other measures.

6. Limitations on major life activities. If the answer to #5 is yes, does the employee’s
impairment substantially limit one or more major life activities? Yes No

Note: Whether an impairment substantially limits the ability of an individual to perform a major
life activity is determined:

 As compared to most people in the general population; and

 Does not need to prevent, or significantly or severely restrict, the individual from performing a
major life activity – the impairment only needs to “substantially limit” the employee’s ability to
perform the major life activity.

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 7. Limitations on major life activities (cont.). If the answer to #6 is yes, which major life
activity(s) is/are affected? Check all major life activities that both (a) are affected by
the employee’s impairment(s) and (b) restrict or limit the employee’s ability to perform
the employee’s job duties.

Major life activities – general life activities:

Bending Learning Sleeping

Breathing Lifting Speaking
Caring for self Performing manual tasks Standing
Concentrating Reading Thinking
Eating Reaching Walking
Hearing Seeing Working
Interacting with others Sitting Other(s) (describe)

Major life activities – operation of major bodily functions:

Bladder Genitourinary Operation of an organ
Bowels Hemic Reproductive
Brain Immune Respiratory
Cardiovascular Lymphatic Sensory organs & skin
Circulatory Musculoskeletal Other(s) (describe)
Digestive Neurological
Endocrine Normal cell growth

8. Commencement of impairment(s). For the impairments identified above, when

did the employee’s impairment(s) commence? If there is more than one impairment,
please specify the start date for each:

9. Performance of essential job functions. Does the employee’s impairment(s) limit

his/her ability to perform the essential functions of the employee’s position (as
defined in the job description) without any accommodation? Yes No

If the answer is yes, please:

a. Identify which essential function(s) the employee is unable to perform without an

accommodation:

LC-7630-5 Page 3 of 5 11/2020

 b. Describe the manner in which the employee’s ability to perform each essential function
is limited:

10. Accommodation(s). Please describe:

Note: Reasonable accommodations may include such things as a modified work schedule,
provision of special equipment, workplace accessibility modifications, shifting of non-essential
duties of the employee’s position, and extended leave of absence to allow time for recovery,
therapy, training, or other disability-related needs.

a. Will a leave of absence assist the employee to return to work? Yes No

b. How will leave assist the employee in returning to work?

c. Duration. What are the dates during which you anticipate the employee will
need the leave of absence?
Continuous leave starting on through

Reduced schedule leave starting on through with an anticipated

schedule of: hour(s) per day; days per week

Intermittent leave starting on through with an anticipated

frequency and duration of absences for (e.g. 1 episode every 3 months lasting 1-2 days):
Frequency: times per week(s) months(s)
Duration: hours or days(s) per episode

Note: You must provide your best medical judgment, based on current information, as to the length
of time the employee will need an accommodation to perform his/her essential job functions.

LC-7630-5 Page 4 of 5 11/2020

 11. Is there another accommodation(s) instead of a leave of absence that will enable the
employee to perform the essential job functions? Yes No
If so please describe:

a. How will the accommodation(s) assist the employee in performing the

essential job functions.

b. Duration. For how long do you anticipate the employee will need the
identified accommodation(s) to perform the essential job functions?
Note: You must provide your best medical judgment, based on current information, as
to the length of time the employee will need an accommodation to perform his/her
essential job functions.

(check one) days weeks months years or permanent

Comments:

12. Additional information. Are you aware of any other information that The Hartford
should consider in assessing whether the employee can perform the essential job
functions with or without accommodation? Yes No

If yes, please describe:

Provider Name (print):

Provider Signature:

Provider Practice/Specialty:

Provider Phone Number: ( )

Provider Address:

Date:

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