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Accomodations

Simone Gummere, a Pharmacy Transition Specialist, has requested a reasonable accommodation under the ADA due to bilateral knee pain that limits her ability to walk, navigate stairs, and perform other physical tasks. The impairment is expected to last for at least six months and requires frequent rest breaks during work. Recommendations for accommodations include allowing for rest breaks and increased time for stair navigation to enable her to perform her job functions effectively.

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7 views3 pages

Accomodations

Simone Gummere, a Pharmacy Transition Specialist, has requested a reasonable accommodation under the ADA due to bilateral knee pain that limits her ability to walk, navigate stairs, and perform other physical tasks. The impairment is expected to last for at least six months and requires frequent rest breaks during work. Recommendations for accommodations include allowing for rest breaks and increased time for stair navigation to enable her to perform her job functions effectively.

Uploaded by

singlejinxs
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Provider’s Statement of Accommodation

Teammate Information
Teammate Name: Simone Gummere Teammate ID: U377850
Job Title: Pharmacy Tranistion Specialist Supervisor: Shanita Edwards
Department Pharmacy Date: 5/21/24
Overview: The above teammate has requested a reasonable accommodation under the Americans
with Disabilities Act (“ADA”) to enable the teammate to perform the essential functions of their
position and/or access a benefit of employment. We ask that you complete the following assessment
to help us better understand the nature of the teammate’s impairment and whether an
accommodation would enable them to perform the essential functions of their job and/or access a
benefit of employment.
Instructions: Please review the attached job description and provide as much detail as possible in
your recommendations when completing this form.
Did you examine this teammate and are you familiar with their medical history? Yes No
Did you review the job description? Yes No
Please list the date you examined the teammate: ______________________________________
3/15/24 - current

Questions to help determine whether the teammate has a disability.


Existence of impairment: For reasonable accommodation under the ADA, the teammate has a
disability if there is a physical or mental impairment that substantially limits one or more major life
activities.
1. Does the teammate have a physical or mental impairment? Yes No
If yes, what is the impairment? ________________________________________________________
bilateral knee pain limiting loading. this includes tolerance for walking, stair navigation,

__________________________________________________________________________________
siting tolerance, and lifting.

__________________________________________________________________________________
Limitations on major life activities: Answer the following questions based on what limitation the
teammate has when their condition is in an active status.
1. Does the impairment substantially limit a major life activity as compared to most people in
the general population. Yes No
2. If yes, what major life activity(s) including major bodily functions) is/are affected? Please
check all that apply.
Bending Learning Sitting
Breathing Lifting Speaking
Caring for Self Performing Manual Tasks Sleeping
Eating Reaching Standing
Hearing Reading Thinking
Interacting with Others Seeing Walking
Other: Please describe: Stair navigation, transfers
Major Bodily Function (Please Check All that Apply)
Bladder Endocrine Neurological
Bowel Genitourinary Normal Cell Growth
Brain Cardiovascular Operation of an Organ
Immune Reproductive Circulatory
Lymphatic Respiratory Digestive
Musculoskeletal Special Sense Organ
Duration: Describe the nature, severity, and anticipated duration of the impairment.
Temporary If temporary, what is the expected duration of the impairment?
Permanent 6 months unless otherwise indicated by follow up exam

Revision Date: January 1, 2024


Questions to help determine whether an accommodation is needed.
A teammate with a disability is entitled to an accommodation only when the accommodation is
needed because of the disability. The following questions may help determine whether the requested
accommodation is needed because of the disability.
1. Based on the attached job description, does the impairment interfere with the teammate’s
ability to perform their job and/or access a benefit of employment? If so, how? Please
describe specifically which job functions, if any, the teammate is having trouble performing.
Limited ability to tolerate prolonged walking, requiring frequent rest breaks at least 2
times per day.
Requires increased time for any required stair navigation with option for rest upon
completion of a flight.

2. Does the teammate have restrictions? If so, please be specific in listing those restriction and
any time requirements.
See above - needs frequent rest breaks to avoid prolonged activity.

3. In your opinion, what accommodation(s) would allow the teammate to perform their job
functions? Please be specific and list as many options as possible.
Already outlined several times above. Re-read number 1.

4. Considering the nature of the teammate’s impairment and job duties (please refer to the job
description) does, the teammate pose a direct threat in the workplace? “Direct threat” means
a significant risk of substantial harm to the health and safety of the teammate or others.
Yes No

5. If yes, please describe the nature of the threat, its severity, the probability of it occurring,
when it may occur, and its duration, to the best of your ability.
Not applicable.

Health Care Provider Information


Print Name: Kelsi Kazmierczak, PT, DPT, OCS, CSCS Phone: (984) 215-5130
Address: UNC Therapy Services at the Ambulatory Care Center (ACC) 102 Mason Farm Rd. Chapel Hill, NC, 27514 Specialty: Physical Therapy

Revision Date: January 1, 2024


Genetic Information Nondiscrimination Act of 2008 Disclosure
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting, or requiring, genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are
asking that you not provide any genetic information when responding to this request for medical
information. “Genetic information,” as defined by GINA, includes an individual’s family medical history,
the results of an individual’s or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus
carried by an individual or an individual’s family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.
5/31/24

Provider Signature: Date:

Revision Date: January 1, 2024

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