Office of Institutional Equity and Accessibility Health Care Provider/Specialist Form

The employee is requesting:(Required)

Accessible Transit Parking Accommodation Other Accommodation

You must make at least one selection.

Is the employee's disability permanent?(Required)

Yes No

This field is required.

Please share the patient's specific diagnosis(es).(Required) This field is required.

Please identify the patient’s condition.(Required) This field is required.

Please list any medication(s) the patient is prescribed to treat their condition. This field is required.

Please describe patient’s work activity restrictions.(Required) This field is required.

Include duration of limitations/restrictions:(Required) This field is required.

Do you have recommendations for accommodations (or any other workplace adjustments) that will help the patient perform their job?(Required) This field is required.

How will the accommodations/adjustments help the patient perform the functions of their job?(Required) This field is required.

If the employee is requesting Accessible Transit or Parking Accommodations, what number of city blocks can the employee walk? This field is required.

If the employee is requesting Accessible Transit or Parking Accommodations, does the employee’s medical condition require door-to-door transportation?

Yes No NA

This field is required.

If the employee is requesting Accessible Transit or Parking Accommodations and the employee's medical condition does not require door-to-door transportation, can the employee ride the Yale Shuttle if the distance between the bus stop and the destination is within the specified walking distance noted above?

Yes No NA

This field is required.

If the employee is requesting a Parking Accommodation, does the employee hold a State of Connecticut handicapped permit?

Yes No NA

This field is required.

If the employee is requesting a Parking Accommodation, would the Accessible Transit meet their needs? If not, please explain. Accessible Transit provides door-to-door pick-up and delivery within the geography of the campus community. This field is required.

Office of Institutional Equity and Accessibility Health Care Provider/Specialist Form

Health Care Provider/Specialist Contact Information

Patient Information

Questions

Supporting Documentation

Submission