UMDNJ Sample Letter from Doctor/Medical
Provider to Support Request for Disability Accommodations
Instructions:� Please have your doctor or medical provider
use this format when providing medical documentation.� The doctor/medical must sign this letter and
provide the letter on his/her official letterhead.
SAMPLE FORMAT
Date:
Ms. Laxmi Vazirani
Workplace Diversity Officer
Office of Workplace Diversity
Re (Patient�s Name)
Dear Ms. Vazirani:
I have been providing (patient�s
name) treatment for (medical condition)
since (date of beginning of treatment).� This condition has the following impact:� describe how the
condition affects the patient).
Due to (diagnosis/the medical condition), I recommend the following workplace accommodations*:
1.
2.
3.
4.
Sincerely,
(Doctor�s Signature)
(Doctor�s Typed/Printed Name)
* Review employee�s job description and
be specific regarding lifting restrictions, walking distances, stairs etc.
* If the proposed accommodations are
temporary, please indicate the duration needed for accommodation, i.e. number
of weeks, etc.