📄 Doctor's Letter Template

Date:

To: Human Resources Department / Accommodations Coordinator
Re: Medical Documentation for Workplace Accommodations

Patient Information:

Name:
Date of Birth:
Employee ID (if known):

To Whom It May Concern:

I am writing to request workplace accommodations for the above-named patient under the Americans with Disabilities Act (ADA). This patient is under my medical care for the following condition(s):

Diagnosis:
Date of Injury/Surgery:

Current Medical Restrictions:
The patient is currently using crutches for mobility assistance and has the following weight-bearing restrictions:

Expected Duration of Restrictions:
Approximately (weeks/months), with follow-up on .

Functional Limitations:

Due to this medical condition, the patient has the following functional limitations that impact work activities:

• Difficulty standing for prolonged periods (> 15-20 minutes)
• Difficulty walking long distances without rest
• Inability to climb stairs safely or quickly
• Difficulty carrying items while using crutches
• Cannot operate foot pedals or controls
• Risk of falls on wet, uneven, or slippery surfaces
• Difficulty with balance and coordination
• Pain with weight-bearing activities
• Fatigue with extended mobility
• Cannot squat, kneel, or crouch

Recommended Workplace Accommodations:

To enable this patient to perform essential job functions safely and effectively, I recommend the following reasonable accommodations:

Physical Workspace Modifications:

• Accessible parking spot near building entrance
• Workstation located near entrance/elevator to minimize walking
• Sit/stand desk or height-adjustable workstation
• Ergonomic chair with lumbar support and adjustable height
• Footrest or leg rest for injured limb elevation
• Clear pathways with 36" minimum width for crutch mobility
• Removal of trip hazards (cords, rugs, clutter) in work area
• Access to nearby restroom facilities
• Modified storage - items at waist height, no bending or reaching

Schedule and Task Modifications:

• Flexible work schedule to attend medical appointments
• Temporary work-from-home arrangement for weeks
• Hybrid schedule (specify days):
• Reduced hours temporarily: hours per week
• Frequent rest breaks (10 minutes every 1-2 hours)
• Modified start/end times to avoid rush hour commuting
• Temporary reassignment from standing tasks
• Assistance with tasks requiring mobility (delivery, errands, etc.)
• Extended lunch break for rest and elevation

Safety and Equipment:

• Exemption from emergency evacuation duties
• Buddy system for stair evacuation if needed
• Access to elevator (no stair-only routes)
• Non-slip mats in work area
• Storage space for crutches when seated
• Cart or rolling bag to transport work materials
• Handrails in corridors and common areas

Communication and Support:

• Virtual meeting attendance instead of in-person (specify duration)
• Excused from off-site travel requirements temporarily
• Modified dress code (e.g., supportive shoes, comfortable clothing)
• Permission to use personal mobility device (scooter, wheelchair) if needed

Additional Accommodations or Special Considerations:

These accommodations are medically necessary and will enable the patient to perform essential job functions during their recovery period. I am available to discuss these recommendations further if needed.

Please contact my office if you require any additional medical documentation or clarification.

Sincerely,