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Disability Questionnaire

Date:

Please answer the following questions telling us briefly why you believe you have been discriminated against by your employer or potential employer.

YOU HAVE SIX (6) MONTHS FROM THE LAST DISCRIMINATORY ACT IN WHICH TO FILE A VERIFIED COMPLAINT WITH THE PHRC, AND 300 DAYS FROM THE LAST DISCRIMINATORY ACT IN WHICH TO FILE UNDER FEDERAL LAW.

First Name:

Last Name:

Address:

City:

County:

State:

Zip/Postal Code:

Work Phone:

Home Phone:

I prefer to be contacted at Work Home

Best Days/Times :

Social Security # :

Your Gender Male Female

Date of Birth :

Age :

Other (if checked) :

If you have been medically diagnosed as having a permanent or long-term physical or mental disability, will you provide a copy of your doctor's diagnosis or sign a release so that we can obtain a copy?

Yes No

What is your actual medical diagnosis by your physician (physical or mental?)

Physician Name:

Address:

City:

County:

State:

Zip/Postal Code:

Telephone Number:

Is the employer aware of your disability?

Yes No

Does the employer have a record of your disability?

Yes No

IF YES, Type of record :

IF YES, Date of record :

How does the employer know about your disability?

What is/was your actual position title, or potential position?

List Job Qualifications (And job description if available):

Were you qualified for this position?

Yes No

What were the qualifications necessary for the job?

Education :

Experience :

Skills :

Other :

Essential functions: (What are/were your actual job duties or most important aspects of performing your job?
Include estimated percentages of time for each function/aspect required.)

Are/were you able to perform the essential functions of your job
WITH reasonable accommodation?

Yes No

Are/were you able to perform the essential functions of your job WITHOUT reasonable accommodation?

Yes No

Did you perform the essential functions of your job satisfactorily?

Yes No

Did you have regularly scheduled performance evaluations?

Yes No

If so, how were you rated on your last two performance evaluations?
(Rating and the date rated, if known). If necessary, please provide copies.

Did you ever request to be accommodated by the employer so that you could perform your job?

Yes No

If so, whom did you talk to and when?

Name, Title and Date:

What did you request? :

Did the employer attempt to provide accommodation?

Yes No

If yes, when ? :

Was an accommodation : Offered Effective Accepted Rejected

If applicable, was an alternative proposed?

Yes No

Was there any consultation by the employer with you?

Yes No

If yes, when (date)? :

Persons present during consultation (if applicable):

If you do need reasonable accommodation to perform the essential functions of your job,
what type of accommodation is required?

Other :

Did you get a notice of discharge from the employer?

Yes No

If YES, submit a copy of the notice. If NO, state the reason given for your discharge by the employer.

Did the employer hire someone to fill your position?

Yes No

If YES, person's name :

MEDICAL QUESTIONS --

Were you asked questions about your disability or about your use of sick leave or Workers' Compensation benefits? (Check appropriate block)

On an application form

Yes No

Before a job offer was made

Yes No

At any time during the employment relationship

Yes No

MEDICAL EXAMINATION (Check appropriate block)

Were you required to take a medical examination before a job offer was made?

Yes No

If not, did you have to take a medical exam at any time that other employees or applicants were not required to take?

Yes No

Was any required medical exam job-related?

Yes No

Did the employer provide assurances that a medical exam would be confidential?

Yes No

Did the employer indicate that your handicap was a threat to the safety of other workers?

Yes No

Do you believe that you were subject to discrimination through a contract?

Yes No

Do you believe you were subject to discrimination on the basis of your relationship or association with an Individual with a Disability?

Yes No

Do you believe that you were discriminated against because the employer perceived or perceives that you have a disability, even though you may or may not in fact have a disability?

Yes No

If YES, please explain further:

ATTORNEY-CLIENT PRIVILEGED COMMUNICATION

Your Initials :

Date Signed :

Enter the text that appears in above image to complete this form: