Amazon Healthcare Provider Form for Accommodation Request Instructions

Check this box if the employee’s restrictions/limitations are temporary and you can provide an anticipated start date and end date.

Check this box if the employee’s restrictions/limitations are permanent (no end date).

Check this box if you cannot predict an end date with reasonable certainty (unknown/indefinite duration).

Provide details describing how often additional breaks are needed and how long each break should last. Fill only if 'Additional Breaks Request Indicator' is 'Yes'.

Enter a mark or note to indicate that the additional breaks accommodation is being requested.

Enter the number of additional breaks needed during each shift. Fill only if 'Additional Breaks Request Indicator' is 'Yes'.

Enter the maximum length of each additional break in minutes. Fill only if 'Additional Breaks Request Indicator' is 'Yes'.

Enter the maximum amount of time the employee can bend during a work shift, if applicable. Fill only if 'Bending' is 'Yes'.

Describe the specific bending restriction or limitation (e.g., frequency, posture limits, or conditions that trigger symptoms). Fill only if 'Bending' is 'Yes'.

Check this box if the employee has a medical limitation that restricts bending as part of their job duties. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe the requested changes to the employee’s work environment, such as work location adjustments or workstation setup modifications.

Enter the maximum amount of time the employee can climb ladders, stairs, or steps during a shift. Fill only if 'Climbing (ladder/stairs/steps)' is 'Yes'.

Describe the specific limitation or restrictions related to climbing ladders, stairs, or steps. Fill only if 'Climbing (ladder/stairs/steps)' is 'Yes'.

Check this box if the employee has any restriction or limitation with climbing ladders, stairs, or steps. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box to indicate the month (MM) of the healthcare provider’s evaluation date.

Check this box to indicate the day (DD) of the healthcare provider’s evaluation date.

Enter the date on which the healthcare provider evaluated the employee.

Enter the employee/patient’s diagnosis if you choose to disclose it. Fill only if 'Pregnancy/childbirth-related condition — Yes' is 'Yes'.

Enter the signature of the employee or the authorized representative signing on the employee’s behalf.

If a representative is signing, enter the representative’s relationship to the employee.

Enter the date the employee or representative signed the authorization.

Enter the employee's full legal name.

Enter the employee's Amazon login alias or username.

Enter the month portion of the employee's date of birth.

Enter the remaining portion of the employee's date of birth (day and year).

Check this box if the medical condition substantially impacts executive functioning or neurodiverse-related activities (e.g., concentration, learning, comprehension, communication). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe whether and how the medical condition(s) substantially impact executive functioning/neurodiverse-related activities such as concentration, learning, comprehension, communication, or other related functions. Fill only if 'Executive Functioning/Neurodiverse' is 'Yes'.

Enter the maximum amount of time per shift the employee can perform gripping, if a time limit applies. Fill only if 'Gripping' is 'Yes'.

Describe the employee’s specific limitation(s) related to gripping. Fill only if 'Gripping' is 'Yes'.

Check this box if the employee has a work restriction or limitation related to gripping (e.g., due to pain, weakness, or reduced hand function). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter the healthcare provider's medical specialty or department.

Enter the full name of the healthcare provider and their professional title/credentials.

Enter the healthcare provider’s office or practice mailing address.

Enter the healthcare provider’s primary contact phone number.

Enter the healthcare provider’s fax number.

Enter the heading text that identifies the start of the Healthcare Provider Portion section.

Enter the healthcare provider’s signature to certify the information provided on this form.

Provide the healthcare provider’s professional stamp and/or signature along with any identifying information typically included on the stamp.

Provide details describing the expected frequency and duration of intermittent absences. Fill only if 'Intermittent Absences' is 'Yes'.

Check this box if the employee needs intermittent time off from work and you will provide the expected frequency and duration of these absences.

Enter any additional information or notes related to the intermittent absences accommodation request.

Enter the number of absences expected in the selected time period (week, month, or year). Fill only if 'Intermittent Absences' is 'Yes'.

Check this box to indicate the expected maximum length of each intermittent absence will be measured in hours. Fill only if 'Intermittent Absences' is 'Yes'.

Enter the maximum amount of time each absence is expected to last (in hours or days as indicated). Fill only if 'Intermittent Absences' is 'Yes'.

Check this box to indicate the expected maximum length of each intermittent absence will be measured in days rather than hours. Fill only if 'Intermittent Absences' is 'Yes'.

Provide any narrative details that clarify the lift/carry time limitation per shift. Fill only if 'Lift/Carry', 'Push/Pull' is 'Yes' (any of fields).

Provide any narrative details that clarify the push/pull time limitation per shift. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if a maximum-hours-per-shift restriction applies to push/pull tasks and you will provide the hour limit(s) in the lines below. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if you are specifying a maximum number of hours per shift the employee can perform lift/carry tasks for the first entry line, and enter the hours in the blank next to it. Fill only if 'Lift/Carry' is 'Yes'.

Enter the maximum hours per shift the employee may perform lift/carry tasks when limited to up to 5 pounds. Fill only if 'Lift/Carry' is 'Yes'.

Check this box if you are specifying a maximum number of hours per shift the employee can perform push/pull tasks for the first entry line, and enter the hours in the blank next to it. Fill only if 'Push/Pull' is 'Yes'.

Enter the maximum hours per shift the employee may perform push/pull tasks when limited to up to 5 pounds. Fill only if 'Push/Pull' is 'Yes'.

Check this box if you are specifying a second maximum-hours-per-shift limit for lift/carry tasks, and enter the hours in the blank next to it. Fill only if 'Lift/Carry' is 'Yes'.

Enter the maximum hours per shift the employee may perform lift/carry tasks when limited to up to 15 pounds. Fill only if 'Lift/Carry' is 'Yes'.

Check this box if you are specifying a second maximum-hours-per-shift limit for push/pull tasks, and enter the hours in the blank next to it. Fill only if 'Push/Pull' is 'Yes'.

Enter the maximum hours per shift the employee may perform push/pull tasks when limited to up to 15 pounds. Fill only if 'Push/Pull' is 'Yes'.

Enter the maximum hours per shift the employee may perform lift/carry tasks when limited to up to 25 pounds. Fill only if 'Lift/Carry' is 'Yes'.

Enter the maximum hours per shift the employee may perform push/pull tasks when limited to up to 25 pounds. Fill only if 'Push/Pull' is 'Yes'.

Check this box if you are specifying a third maximum-hours-per-shift limit for lift/carry tasks, and enter the hours in the blank next to it. Fill only if 'Lift/Carry' is 'Yes'.

Check this box if you are specifying a third maximum-hours-per-shift limit for push/pull tasks, and enter the hours in the blank next to it. Fill only if 'Push/Pull' is 'Yes'.

Describe any other time-per-shift limitations for lift/carry and/or push/pull that are not captured above. Fill only if 'Lift/Carry' is 'Yes'.

Check this box if you are specifying a fourth maximum-hours-per-shift limit for lift/carry tasks, and enter the hours in the blank next to it. Fill only if 'Lift/Carry' is 'Yes'.

Enter the overall maximum hours per shift allowed for lift/carry, if applicable. Fill only if 'Lift/Carry' is 'Yes'.

Check this box if you are specifying a fourth maximum-hours-per-shift limit for push/pull tasks, and enter the hours in the blank next to it. Fill only if 'Push/Pull' is 'Yes'.

Enter the overall maximum hours per shift allowed for push/pull, if applicable. Fill only if 'Push/Pull' is 'Yes'.

Enter the overall maximum weight the employee is permitted to handle. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe the specific maximum weight limitations and any conditions or restrictions that apply. Fill only if 'Lift/Carry', 'Push/Pull' is 'Yes' (any of fields).

Enter the maximum weight the employee can lift and carry. Fill only if 'Lift/Carry' is 'Yes'.

Check this box if the employee has a maximum weight limit for pushing and/or pulling. Fill only if 'Push/Pull' is 'Yes'.

Check this box if the employee has a maximum weight limit for lifting and/or carrying. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter the lift/carry weight limit value to be used for the “Up to 5 pounds” option, if applicable. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if the employee may lift/carry no more than 5 pounds. Fill only if 'Lift/Carry' is 'Yes'.

Check this box if the employee may push/pull no more than 5 pounds of force/weight. Fill only if 'Push/Pull' is 'Yes'.

Check this box if the employee may lift/carry no more than 15 pounds. Fill only if 'Lift/Carry' is 'Yes'.

Check this box if the employee may push/pull no more than 15 pounds of force/weight. Fill only if 'Push/Pull' is 'Yes'.

Check this box if the employee may push/pull no more than 25 pounds of force/weight. Fill only if 'Push/Pull' is 'Yes'.

Check this box if the employee may lift/carry no more than 25 pounds. Fill only if 'Lift/Carry' is 'Yes'.

Provide any other maximum weight limit not covered by the listed options. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if the lift/carry maximum weight limit is different than the listed options and will be described in the space provided. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if the medical condition substantially impacts medical-related life activities (e.g., being immunocompromised, using a medical device, or needing personal medical treatment administration). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe whether and how the medical condition(s) substantially impact the employee’s medical-related major life activities (e.g., being immunocompromised, use of a medical device, or personal medical treatment administration). Fill only if 'Medical' is 'Yes'.

Check this box if the employee’s medical condition substantially impacts mental health-related major life activities (e.g., cognitive/behavioral functioning, social interactions, written/verbal interactions, or sensitivity to triggers). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe whether and how the medical condition(s) substantially impact the mental health-related major life activity. Fill only if 'Mental Health' is 'Yes'.

Enter the other mental health-related major life activity impacted if it is not already listed in the Mental Health section. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if the patient’s medical condition substantially impacts mobility activities (e.g., gross motor skills, sitting/standing, walking, lifting, fine motor/dexterity, or other mobility). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe the specific mobility-related major life activity(ies) that are substantially impacted (e.g., walking, standing, lifting, gross motor, fine motor/dexterity). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Explain whether and how the medical condition(s) substantially impact the mobility activity(ies) identified. Fill only if 'Mobility' is 'Yes'.

Check this box if the accommodation needed is to not be required to work mandatory extra time (MET) and you are an hourly employee.

Describe the specific limits or conditions you need regarding mandatory extra time (e.g., no overtime, no extra shifts, or specific days/times you cannot stay late). Fill only if 'No Mandatory Extra Time (hourly employees only)' is 'Yes'.

Enter an indicator (such as an “X”) to show you are requesting no mandatory extra time.

Check this box if the hourly employee is requesting an accommodation to not participate in shift bidding.

Enter a mark or short note indicating that the employee is requesting the No Shift Bid accommodation.

Provide details explaining the requested No Shift Bid accommodation and any relevant schedule limitations or requirements. Fill only if 'No Shift Bid (hourly employees only)' is 'Yes'.

Enter the other job function/activity (not listed above) that is restricted due to the employee’s limitation. Fill only if 'Other (Restricted job function)' is 'Yes'.

Enter the maximum number of hours per shift the employee can perform the other restricted activity, if applicable. Fill only if 'Other (Restricted job function)' is 'Yes'.

Describe the specific limitation or restrictions that apply to the other activity. Fill only if 'Other (Restricted job function)' is 'Yes'.

Check this box if the employee has a different activity or job-function limitation not listed (e.g., not bending, climbing, gripping, reaching, sitting, squatting, standing, or walking). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter any additional changes or limitations not covered elsewhere on the form.

Enter the name or type of other equipment involved in the change to equipment operation.

Describe the change or limitation related to operating the other equipment listed. Fill only if 'Other Equipment' is specified.

Describe whether and how the medical condition(s) substantially impact the other major life activity listed. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter the other major life activity that is substantially impacted and not already listed above. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter the other operational request or item not covered by the listed categories.

Provide details explaining the other request, including what is needed and any relevant context for the accommodation. Fill only if 'Other Request Item' is specified.

Enter the name or brief description of the other schedule/time/work-duration change being requested.

Provide full details of the requested other schedule/time/work-duration change. Fill only if 'Other Schedule/Time Change (Specify)' is 'Yes'.

Provide any additional notes or explanation about the other schedule/time/work-duration change request.

Describe whether and how the medical condition(s) affects the identified major life activity. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter the major life activity that is substantially impacted by the medical condition(s). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Use this box when indicating the year portion of the anticipated start date for a permanent restriction/limitation. Fill only if 'Permanent' is 'Yes'.

Use this box when indicating the month portion of the anticipated start date for a permanent restriction/limitation. Fill only if 'Permanent' is 'Yes'.

Use this box when indicating the day portion of the anticipated start date for a permanent restriction/limitation. Fill only if 'Permanent' is 'Yes'.

Check this box if the employee’s restrictions/limitations are permanent and you are providing the anticipated start date. Fill only if 'Permanent' is 'Yes'.

Enter the type(s) of power equipment involved (e.g., forklift, reach truck, scissor lift).

Describe the requested change or limitation related to operating power equipment and any relevant details. Fill only if 'Power Equipment Type' is specified.

Check this box if the employee needs a change or restriction related to operating power equipment.

Check this box if the change or restriction specifically applies to operating forklifts, reach trucks, scissor lifts, or similar power equipment.

Enter the employee’s expected date of delivery if the request concerns a pregnancy and the employee has not yet given birth. Fill only if 'Pregnancy/childbirth-related condition — Yes' is 'Yes'.

Check this box if the accommodation request concerns a pregnancy- or childbirth-related condition (and provide the expected delivery date if the employee is pregnant and has not yet given birth).

Check this box if the accommodation request does not concern a pregnancy- or childbirth-related condition.

Enter the maximum amount of time the employee can perform reaching during a shift, if applicable. Fill only if 'Reaching' is 'Yes'.

Describe the specific reaching limitation and any restrictions or conditions that apply. Fill only if 'Reaching' is 'Yes'.

Check this box if the employee has a work restriction or limitation related to reaching (e.g., overhead, forward, or repetitive reaching). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter a brief summary of the reduced-time work limitation being requested.

Provide detailed information about the reduced-time schedule requested (for example, the maximum hours allowed per week or day). Fill only if 'Reduced Time Summary' is 'Yes'.

Check this box if the employee must have restrictions or changes related to lifting or carrying as part of their job functions. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if the employee must have restrictions or changes related to pushing or pulling as part of their job functions. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter details describing the specific job function(s) that must be restricted (e.g., lift/carry or push/pull) and any relevant limitations or context. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe the safety equipment request and explain what is needed and why it is needed. Fill only if 'Safety Equipment Requested' is specified.

Enter the specific safety equipment being requested (e.g., safety shoes, gloves, or other protective equipment).

Provide any additional information or explanation that continues Section 1 (Medical Condition), including details about how the condition affects the employee’s work or relates to the accommodation request.

Describe the employee’s job-related restrictions and limitations (e.g., activities they cannot do or conditions that limit performance). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Explain how the listed restrictions and limitations affect the employee’s ability to perform their job duties or meet job requirements. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe any assistive technology or alternate formats that would help the employee perform their job duties (e.g., screen reader software, enlarged monitor, speech-to-text software, push pads for doors, alternate keyboard or mouse).

Describe any additional training, temporary job coach support, or other individualized support that would help the employee perform their job duties.

Enter the sensory-related major life activity that is substantially impacted (e.g., vision, hearing, speech, or other sensory). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if the medical condition substantially impacts any sensory major life activity (e.g., vision, hearing, speech, or other sensory function). Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Describe whether and how the medical condition(s) substantially impacts the identified sensory major life activity. Fill only if 'Sensory' is 'Yes'.

Provide additional details about the specific sensory function(s) affected and the nature of the limitation. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter the maximum amount of time the individual can sit per shift, if a limit applies. Fill only if 'Sitting' is 'Yes'.

Describe the specific limitation(s) or restrictions related to sitting. Fill only if 'Sitting' is 'Yes'.

Check this box if the employee has a limitation related to sitting and needs restrictions or accommodations for seated work. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter any text indicating that the specific shift availability accommodation option applies (as shown on the form).

Describe the employee’s specific shift availability restrictions or preferred working hours (e.g., available between certain times or unable to work overnight). Fill only if 'Specific Shift Availability Selection' is 'Yes'.

Enter the maximum amount of time the employee can squat, if applicable (e.g., per shift). Fill only if 'Squatting' is 'Yes'.

Describe the employee’s specific limitation or restriction related to squatting. Fill only if 'Squatting' is 'Yes'.

Check this box if the employee has a medical limitation or restriction related to squatting that should be accommodated at work. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Enter the maximum amount of time the employee can stand, if there is a standing time limit. Fill only if 'Standing' is 'Yes'.

Describe the employee’s standing limitation and any restrictions or conditions that apply while standing. Fill only if 'Standing' is 'Yes'.

Check this box if the patient has a medical limitation or restriction related to standing as part of their job duties. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Fill in this box with the second digit of the month for the anticipated start date of the temporary restrictions/limitations. Fill only if 'Temporary' is 'Yes'.

Fill in this box with the first digit of the month for the anticipated start date of the temporary restrictions/limitations. Fill only if 'Temporary' is 'Yes'.

Enter the anticipated start date for the temporary accommodation or restriction period. Fill only if 'Temporary' is 'Yes'.

Fill in this box with the first digit of the month for the anticipated end date of the temporary restrictions/limitations. Fill only if 'Temporary' is 'Yes'.

Fill in this box with the second digit of the month for the anticipated end date of the temporary restrictions/limitations. Fill only if 'Temporary' is 'Yes'.

Enter the anticipated end date for the temporary accommodation or restriction period. Fill only if 'Temporary' is 'Yes'.

Check this box if the employee’s restrictions/limitations are temporary and you can provide anticipated start and end dates. Fill only if 'Temporary' is 'Yes'.

Enter the end date to use for the unknown/indefinite duration period (no later than 6 months from now). Fill only if 'Unknown/Indefinite' is 'Yes'.

Enter the specific vehicles involved (e.g., van, truck) and any relevant details about the vehicle change needed.

Describe the requested change or limitation related to operating vehicles, including what tasks cannot be performed or what modifications are needed. Fill only if 'Vehicle Equipment Details' is specified.

Check this box if the employee needs a change or restriction related to operating vehicles such as a van or truck.

Enter the maximum amount of time the employee can walk (if applicable). Fill only if 'Walking' is 'Yes'.

Describe the employee's walking limitation and any restrictions or conditions that apply. Fill only if 'Walking' is 'Yes'.

Check this box if the employee has a restriction or limitation related to walking as part of their job duties. Fill only if 'Does the employee have a disability or medical condition that impacts their work?' is 'Yes'.

Check this box if the employee has a disability or medical condition that impacts their work.

Check this box if the employee does not have a disability or medical condition that impacts their work (and then provide the required explanation on how the request is connected to employment).

If the employee’s condition does not impact their work, explain how the accommodation request is connected to the employee’s employment. Fill only if 'No' is 'Yes'.

Describe how the employee’s disability or medical condition impacts their ability to perform their job duties and what work-related limitations result. Fill only if 'Yes' is 'Yes'.

Enter any specific details about the requested change or restriction related to working from heights.

Describe the working-from-heights limitation or accommodation needed and any relevant conditions or examples. Fill only if 'Working From Heights Change Details' is specified.

Check this box if the employee needs a change or restriction related to working from heights as part of their job duties.

Describe the requested change or limitation related to working in extreme temperatures and what accommodation is needed. Fill only if 'Extreme Temperature Environment Details' is specified.

Check this box if the employee needs a change or accommodation related to working in extreme hot or cold temperatures (such as in a freezer area).

Enter details about the extreme temperature environment involved (for example, freezer, cooler, or other hot/cold area) and any relevant specifics.