Your Health Care Provider’s Letterhead
[Date]
To Whom It May Concern:
I am the treating [job title or description, such as physician, psychiatrist, psychologist, therapist, social worker, case worker, or health care professional] for [name of employee or applicant].
[Name] has [optional: name or description of employee’s medical condition,] a medical condition that [substantially*] limits [Name]’s major life activities, including [fill in relevant major life activities, such as: caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, or the operation of major bodily function].
As a result of [Name]’s disability, [she/he] seeks an accommodation from [employer].
[Describe situation and how accommodation will assist employee by enabling him/her to perform job or to maintain health.]
[Name] will require this accommodation from [Start Date] to [End Date] with a possible need for extension upon evaluation.
[Example 1] As a result of [Name]’s disability, she occasionally experiences episodes of disorientation and dizziness. During these episodes, [Name] must sit or lie down for a few minutes to recover. Therefore, [Name] needs, as an accommodation, permission to take these short breaks.
[Example 2] As a result of [Name]’s disability, [she/he] is extremely sensitive to distractions, including noise, colors and light. When these distractions are present, [Name] has difficulty concentrating on [his/her] job. Therefore, [Name] needs, as an accommodation, a workspace in which these distractions are reduced.
Signature and license number *Federal law (the ADA) requires that the condition “substantially limit” a major life activity. State law (the FEHA) requires that the condition “limit” a major life activity.