Introduction
Job modifications are changes to a job that allow an employee to continue working while accommodating their health condition or disability. Healthcare providers play a crucial role in assessing the need for job modifications and providing recommendations. This questionnaire provides a structured approach for healthcare providers to evaluate and document job modification requests.
Section 1: Patient Information
- Patient Name:
- Date of Birth:
- Medical Diagnosis:
- Date of Diagnosis:
- Current Functional Limitations:
Section 2: Job Description and Duties
- Job Title:
- Employer:
- Job Description:
- Essential Job Functions:
Section 3: Evaluation of Job Modifications
A. Physical Limitations and Required Modifications
- Describe any physical limitations that impact the employee’s ability to perform their job:
- List specific job tasks or activities that are currently difficult or impossible for the employee to perform:
- Recommend any job modifications that would address these physical limitations:
B. Cognitive and Behavioral Limitations and Required Modifications
- Describe any cognitive or behavioral limitations that impact the employee’s ability to perform their job:
- List specific job tasks or activities that are currently difficult or impossible for the employee to perform:
- Recommend any job modifications that would address these cognitive or behavioral limitations:
C. Other Accommodations and Support
- Are there any other accommodations or support measures that would assist the employee in performing their job?
- List any specific equipment, assistive devices, or work schedule adjustments that would be beneficial:
D. Impact on Job Performance and Patient Safety
- Describe how the job modifications would impact the employee’s job performance:
- Discuss any potential risks to patient safety associated with the proposed modifications:
Section 4: Recommendations
- Recommend specific job modifications that would allow the employee to safely and effectively perform their job:
- Provide a timeline for implementing the recommended modifications:
- Monitor the employee’s progress and make any necessary adjustments to the modifications:
Section 5: Documentation and Signature
- Healthcare Provider Signature:
- Date:
Benefits of Using a Questionnaire
- Structured and Efficient: Provides a consistent framework for evaluating job modification requests, ensuring a thorough and objective assessment.
- Accurate and Comprehensive: Captures all relevant information, including patient limitations, job requirements, and recommended modifications.
- Saves Time: Streamlines the process of gathering and documenting necessary information, reducing administrative burden.
- Improves Communication: Facilitates clear and concise communication between healthcare providers, employees, and employers.
Conclusion
This questionnaire serves as a valuable tool for healthcare providers to assess and recommend job modifications for employees with health conditions or disabilities. By providing a structured approach for evaluation, documentation, and communication, it enhances the efficiency and effectiveness of the job modification process, ultimately promoting the well-being of both employees and organizations in the healthcare sector.