Workforce Restrictions and Leave Management Medical Accommodation Forms Package Package Includes: Request for Medical Accommodation in Employment (4 pages) Instructions for completing the request Request for Medical Accommodation in Employment Form Physician s Certification for Employee Accommodations (5 pages) Instructions for Physician or Medical Provider Physician s Certification for Employee Accommodations Form Support Medical Leave Of Absence/Return to Work/Temporary Restrictions Form (1 page) Form to Support Medical Leave of Absence Form to Return to Work from Medical Leave of Absence Form to request Temporary Restriction(s) Package Includes 11 Total Pages (Including Cover Sheet) Package Cover Sheet
Request for Medical Accommodation in Employment Instructions Instructions for Cast Member To facilitate the processing of your request for a medical accommodation in the workplace, please follow the instructions listed below. Medical information and records will be treated confidentially. A. If you believe you need an accommodation in employment under federal, state or local law, use this form to request any type of accommodation for a physical or mental disability. B. Complete the Request for Medical Accommodation in Employment Form. Ensure that you have provided all requested information. Please sign and date the certification at the bottom of the form. C. Complete and sign the Cast Member section of the Physician s Certification for Employee Accommodations Form and take the form to your doctor. Note: Both the instructions and the above forms can be obtained by printing them from the HUB - Health Services Disability Management Site or by visiting your Health Services office. At Disneyland, the Health Services office is located on the 2 nd floor of the Cash Management Building behind Pizza Port. At Walt Disney World, the Health Services office is located behind EPCOT in the Cast Parking Lot across from the Center for Living Well. D. Request that your doctor fully complete the Provider section of the Physician s Certification for Employee Accommodations Form. This documentation must be completed and signed by an appropriate licensed medical practitioner (usually an MD Medical Doctor or a DO Doctor of Osteopathy) with expertise on your medical condition who has direct knowledge of you and your specific disability. Responses to all information requested and your doctor s signature are required before the form can be processed. E. Submit both the Request for Medical Accommodation in Employment Form and the Physician s Certification for Employee Accommodations Form to Health Services for processing. Failure to submit both fully completed forms will result in a delay of processing your request. If you are working at Disneyland Resort, please submit your packet in one of the following ways: Fax Number Interoffice Mailing Address: External Mailing Address: (714) 781-4249 Disney Parks and Resorts Disneyland Resort Health Services Health Services PO Box 3232 DL361D Anaheim, CA 92803-3232 If you are working at Walt Disney World, please submit your packet in one of the following ways: Fax Number Interoffice Mailing Address: External Mailing Address: (407)938-4105 Disney Parks and Resorts Walt Disney World Health Services Epcot Health Services 9600 P.O. Box 10,000 Lake Buena Vista, FL 32830 F. Request for a workplace accommodation will be promptly considered to determine if the request meets the criteria established by law. G. If needed, we may contact you to obtain additional information regarding your requested accommodation or any other accommodation. If you have questions you may contact: Disneyland Resort Health Services 714-781-4200 or Walt Disney World Health Services 407-560-7005. Request for Medical Accommodation in Employment (Instructions) Page 1 of 4
Request for Medical Accommodation in Employment Instructions Instructions for Cast Member Completing the Questions 1) What is the medical condition or disability for which you are requesting an accommodation? Please tell us the name(s) of the medical problem(s) you are having that affect your ability to do your job. 2) When were you first diagnosed with this medical condition or disability? Please give the approximate date (s) when your physician first told you that you had the medical problem(s) or that you developed the medical problem(s). Be as specific as you can, but stating how many months or years it has been since you first found out about your medical problem is also acceptable. 3) Is this medical condition temporary, permanent, or recurring? If temporary, how long do you expect to have the medical condition or disability? If recurring, how often are recurrences expected? Please tell us if you will have this medical problem forever or if it is something that you expect will get better. If it is going to get better (such as surgery or a broken bone) how long do you expect it to last or how long did your doctor tell you it might last. If it is a problem that comes and goes, how many times a year does it happen and for about how long each time. 4) How does this medical condition or disability impact your ability to perform the essential functions of your regular job? (You must be able to perform the essential functions of your job.) Think about the duties that you have to do at work and tell us how your medical problem(s) stops you from doing or makes it difficult for you to do those duties. 5) How does this medical condition or disability substantially limit major life activities? Major life activities include, but are not limited to, walking, standing, sitting, eating, seeing, hearing, using the bathroom, breathing etc. Tell us how your medical problem(s) affects your ability to do any of these type activities. 6) Are you currently receiving any accommodations in the workplace? If yes, please describe. Tell us about any changes your leader is already making for you at work because of your medical problem(s), such as letting you wear a brace, sit down when you are tired, have others carry heavy items, etc. 7) Are you currently receiving any accommodations outside the workplace? If yes, please describe. Tell us if you have had any changes made at home or at another job because of your medical problem(s.) 8) Check any of the following that you use. Please check any of the items that you are currently using to help you with your disability. 9) Describe the requested workplace accommodation. Please tell us what changes you are asking for your job, or what activities you want to be allowed to do/not do so you can do your job. 10) How will this accommodation assist you in performing the essential functions of your job? Please describe how these changes or restrictions will let you be able to do your job duties. Request for Medical Accommodation in Employment (Instructions) Page 2 of 4
Request for Medical Accommodation in Employment Form CAST MEMBER COMPLETES Date of Request Cast Member ID Cast Member Name Cast Member Mailing Address Your Job Title: Cell Phone # Home Phone # Work Phone # Leader Name 1) What is the medical condition or disability for which you are requesting an accommodation? 2) When did you first find out about this medical condition or disability? 3) Is this medical condition or disability temporary, permanent, or recurring? If temporary, how long do you expect to have the medical condition or disability? If recurring, how often are recurrences expected? 4) How does this medical condition or disability impact your ability to perform the essential functions of your regular job? (You must be able to perform the essential functions of your job). 5) How does this medical condition or disability substantially limit major life activities? 6) Are you currently receiving any accommodations in the workplace? If yes, please describe. 7) Are you currently receiving any accommodations outside the workplace? If yes, please describe. COMPLETE AND RETURN TO HEALTH SERVICES Request for Medical Accommodation in Employment Form Page 3 of 4
Request for Medical Accommodation in Employment Form CONTINUED 8) Check any of the following that you use: Manual Wheelchair Powered Wheelchair Powered Scooter Guide Animal Crutches Walker Hearing Aids Oxygen Cane Sight Assistive Devices (other than eyeglasses or contacts) Other 9) Describe the requested workplace accommodation. 10) How will this accommodation assist you in performing the essential functions of your job? Certification I certify that I have an impairment which substantially limits one or more major life activities and for which I am requesting an accommodation in the workplace as described above. I hereby authorize any physician, surgeon, practitioner or other health care provider (any hospital or any other medical service organization), any insurance company or any other institution or organization to release to the Company and to each other any medical information acquired related to my disability for the purpose of processing my request for workplace accommodation. I further certify that all statements made in this form are true and correct, and realize that falsification or misrepresentation of this or any other Company documents may result in termination. Signature Print Name/ID # Date COMPLETE AND RETURN TO HEALTH SERVICES Request for Medical Accommodation in Employment Form Page 4 of 4
Physician s Certification for Employee Accommodations Instructions To the Cast Member: Please have this documentation completed by an appropriate licensed medical practitioner (usually an MD Medical Doctor or a DO Doctor of Osteopathy) with expertise on your medical condition who has direct knowledge of you and your specific disability. Any report submitted with this form must be current and on the office letterhead, typed, dated, and contain the original signature of the medical provider. PLEASE COMPLETE AND SIGN THE CAST MEMBER SECTION BOX on PAGE 4 of 5 Instructions for Physicians Completing this Form To the Physician: (For additional instructions, see the section entitled Instructions for Physicians Completing this Form ) Thank you for assisting your patient in requesting a workplace accommodation due to their disability. Please provide: 1. Detailed information about your patient s medical condition and prognosis related to their disability (do not disclose unrelated medical information or genetic information). 2. The specific findings (physical exam, imaging studies, lab tests, etc.) that you used to make the determination of the severity of the condition, and in determining the restriction(s) needed. 3. The specific restrictions that are required because of this disability and information used in determining these restrictions. 4. A detailed explanation of the medical facts that support the need for each requested restriction. In addition, you may also provide other supporting documentation you believe will assist in determining the nature of your patient s disability and restrictions they require. Examples of the type of information you may provide include the results of testing, examinations, imaging studies, dictations, letters, etc. that help clarify the nature and severity of the disability and the required restriction. Please note that any report submitted in support of this form must be current and on the office letterhead, typed, dated, and contain the original signature of the medical provider. It is important to recognize that accommodation needs can change over time and may require you to submit updated information. Please note that a prior history of a specific accommodation does not, in and of itself, mean that a similar accommodation is currently required. All responses to the questions below should pertain to the medical conditions related to the disability(s). Please do not provide any medical information (including family history or other genetic information) other than the information requested to assess the scope of the disability and the need for the accommodation(s). If the submitted documentation is inadequate, or does not address the individual s current level of functioning and need for accommodations, it will result in a delay in consideration of your patient s request for accommodation. Physician s Certification for Employee Accommodation (Instructions) Page 1 of 5
Physician s Certification for Employee Accommodations Instructions Instructions for Physicians Completing this Form Disability Background Information: A disability is a physical or mental condition that limits (in California) or substantially limits one or more major life activities (MLAs). Examples of MLAs include but are not limited to major bodily functions, such as functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, circulatory, respiratory, endocrine, hemic, lymphatic, musculoskeletal, special sense organs and skin, genitourinary, cardiovascular systems, and reproductive functions. MLAs also include caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, sitting, reaching, interacting with others, and working. Restrictions: It is important that the need for the restriction written be supported by medical documentation that is adequate in scope or content. Appropriate medical documentation might include: a) Office notes including history and physical examination (please do not include genetic information or family history) b) Results of x-rays or other imaging studies that address the severity of the condition c) Results of direct observation, interview, or tests d) Medical provider dictation (must be on letterhead, dated and signed by provider) Simply indicating the restriction is medically necessary is helpful, but not sufficient. All information provided must be current. Response to Questions: 1) Date of last evaluation: Please document the last day you saw your patient for the condition(s) related to this disability request. 2) Are you a licensed medical or psychological practitioner with expertise on your patient s medical/psychological condition with direct knowledge of your patient s specific disability? This documentation should be completed by a licensed practitioner (typically an MD or DO), with appropriate training, experience and expertise who also has direct knowledge of the applicant and their disability. For example, an ophthalmologist or optometrist would normally complete the form for a visual condition and a clinical psychologist or psychiatrist would complete the form for a mental health condition. Appropriate training, expertise, and experience with the applicable medical or psychiatric condition are essential. When you sign the form you will also need to provide your name, title, professional credentials, the state in which you practice, and your area of specialization. 3) Description of condition(s) for which accommodation is requested. Often this will be the diagnosis (e.g., diabetes, HTN, rheumatoid arthritis, etc): Please use specific language in indicating the condition related to the disability, avoiding terms such as suggest, probable or is indicative of. Examples of some conditions which are considered disabilities include: Deafness, Cerebral Palsy, Diabetes, Blindness, Epilepsy, Autism, HIV infection, Cancer, Muscular Dystrophy, and Multiple Sclerosis. Please indicate the future prognosis of the medical condition. Is the condition temporary or permanent, progressive or stable? Physician s Certification for Employee Accommodation (Instructions) Page 2 of 5
Physician s Certification for Employee Accommodations Instructions Instructions for Physicians Completing this Form 4) Please specify the nature and severity of all physical or mental impairments (with and without medical treatment) that are related to the requested accommodation. This information is critical in determining the need for specific accommodation. Some individuals have conditions that would be considered a disability, but do not require specific accommodation in the workplace. For example, many individuals with hypertension or diabetes are able to work without restrictions of any kind. However, others with the same condition may have significant impairment that prevents them from working without an accommodation. 5) List all restrictions required by your patient. Please enter the restrictions you are recommending for your patient in the workplace. You will need to support the need for each restriction listed in Question #5. Be as specific as possible and use direct, clear language. It is helpful if the restriction is easy to interpret objectively (e.g. no lifting more than 10 lbs). Please avoid language such as avoid lifting too much, or may stand as tolerated. 6) Provide information to support why the requested restriction is necessary for the condition(s) listed in question #3. This information must be very specific. A detailed explanation as to why each restriction is recommended must be provided and should be correlated with specific functional limitations determined through interview, observation, and/or testing. For example, for your patient with significant osteoarthritis of the knee who you indicate needs a restriction of No standing more than 5 minutes per hour, you might detail the x-ray findings as showing Severe joint space narrow, or significant osteophyte formation. 7) Describe whether any symptoms related to the patient s condition (with and without medical treatment) cause substantial impairment in a major life activity. Please indicate if the medical condition affects one or more major life activities. This information is often essential in determining if an individual has a disability that requires a specific workplace accommodation. Although a medical condition may be considered a disability in one patient, this does not imply that the impact and need for accommodation will be the same for all persons with the condition. For example, some persons with COPD may not have any significant limitation in breathing, while others may require oxygen. Providing this type of information will likely be very helpful in reviewing this request. 8) Does your patient require assistance in one or more major life activities because of their disability? Please explain: For example, they require help with eating, dressing, bathing, etc. 9) Please list any devices such as a wheelchair, walker, cane, crutches, appliances, braces, etc. used by your patient: Please list any such assistive devices that are used, even if only intermittently. 10) Are you aware of any job duties that your patient cannot perform? Please explain. If you have specific knowledge of an activity that is part of your patient s job duties that they cannot perform, please indicate it here, and explain why. For example, indicating your patient cannot enter a walk-in freezer unit because they have severe Raynaud s disease that causes significant ischemia to their fingers upon exposure to cold temperature. 11) Is this patient a relative of yours? It is helpful to have this form completed by a provider that is not a close relative of the applicant. Physician s Certification for Employee Accommodation (Instructions) Page 3 of 5
Physician s Certification for Employee Accommodations Form Cast Member Name Cast Member Mailing Address Cast Member ID # Home Phone # Cell Phone # I hereby authorize the release to Walt Disney World Co. / Disneyland Resort of any medical information/records pertaining to my disability for the purpose of processing my request for workplace accommodation. In addition, I understand that any misrepresentation made to obtain such an accommodation is grounds for immediate termination. Cast Member Signature Date PHYSICIAN COMPLETES THIS SECTION Please respond to the following questions regarding your patient: 1) Date of last evaluation: / / 2) Are you a licensed medical or psychological practitioner with expertise on your patient s medical/psychological condition with direct knowledge of your patient s specific disability? Yes No 3) Description of condition(s) for which accommodation is requested: Condition (Diagnosis) Date of Onset Expected End Date Condition (Diagnosis) Date of Onset Expected End Date Condition (Diagnosis) Date of Onset Expected End Date 4) Please specify the nature and severity of the condition of all physical or mental impairments (with and without medical treatment) that are related to this request. 5) List all restrictions required by your patient. No lifting, pushing or pulling more than lbs No sitting more than minutes per hour No standing or walking more than minutes per hour No kneeling more than times per hour No squatting more than times per hour No climbing more than steps per hour Other RETURN THIS FORM TO HEALTH SERVICES Physician s Certification for Employee Accommodation Form Page 4 of 5
Physician s Certification for Employee Accommodations Form 6) Provide information to support why the requested restriction is necessary for the conditions(s) listed in question #3. This information must be very specific. 7) Describe whether any symptoms related to the patient s condition (with and without medical treatment) cause substantial impairment in a major life activity. 8) Does your patient require assistance in one or more major life activities because of their disability? Please explain: 9) Please list any devices such as a wheelchair, walker, cane, crutches, appliances, braces, etc. used by your patient: 10) Are you aware of any job duties that your patient cannot perform? Please explain. 11) Is this patient a relative of yours? Yes No If yes, please give relationship Doctor Signature Print Provider Name License # Date Phone State Medical Specialty Address RETURN THIS FORM TO HEALTH SERVICES Physician s Certification for Employee Accommodation Form Page 5 of 5
Support Medical Leave Of Absence/Return to Work/Temporary Restriction Form Disney Parks and Resorts Health Services Disney Parks and Resorts Health Services P.O. Box 10000; Lake Buena Vista, FL 32830 DL362D; PO Box 3232; Anaheim, CA 92803-3232 PHONE: (407) 560-7005; FAX: (407) 938-4105 PHONE: ( 714) 781-4200; FAX: (714) 781-4249 INSTRUCTIONS TO CAST MEMBER: This form may be completed in accordance with company policy to provide documentation supporting your need for a medical leave of absence, temporary restrictions for a short term medical condition and as a written release to return to work. Documentation must be submitted at the beginning of the leave, for any leave extension, and no more than five (5) days prior to your return to work. Please fax or mail this completed form using the information listed above to the Health Services location where you work. Name: DOB: Address: ID #: City/State/Zip: Phone #: Your Occupation/Job Duties: Department: Supervisor: Phone #: I authorize the physician signing this form to release any medical information to a healthcare provider representing the Company for the purpose of processing my return to work and/or clarifying and authenticating this form. Note: This authorization does NOT limit the Company s access to medical information under the Florida Worker s Compensation Act or any other applicable law. Cast Member Signature: Date: / / INSTRUCTIONS TO HEALTH CARE PROVIDER: Your patient has requested that you provide us with the information indicated below concerning his/her absence from work and/or his/her need for temporary work restrictions. Incomplete forms will be returned to your patient. Please enter the dates your patient was unable to work for medical reasons: First date: / / If returning to work, the actual return to work date: / / If not returning to work, please enter the estimated duration of the medical leave: Begin Date: / / Through: / / Medical Reason Unable to Work (Condition/Surgery): Temporary Restrictions (this form can only be used to enter temporary restrictions unrelated to a disability): Indicate any medically necessary work restrictions below. (If you leave this section blank, the Company will assume that your patient does not require any medically necessary work restrictions): Begin Date: / / Through: / / List all restrictions required by your patient: No lifting, pushing or pulling more than lbs No sitting more than minutes per hour No standing or walking more than minutes per hour No kneeling more than times per hour No squatting more than times per hour No climbing more than steps per hour List any tasks your patient cannot perform Other Health Care Provider Signature: Print Name: Date: Degree: Phone #: Fax #: RETURN THIS FORM TO HEALTH SERVICES Support Medical Leave of Absence/Return to Work/Temporary Restriction Page 1 of 1