Intake Form: Accommodations Medical Opinion / David Medical Services

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This form is for federal employees and applicants seeking an independent medical opinion (IMO) to support a workplace reasonable accommodation request.

David Medical Services provides physician-authored evaluations of medical diagnoses, functional limitations, and their relationship to essential job duties. Our opinions are based on the medical evidence provided and applicable clinical principles.

Our physicians may evaluate whether the available medical evidence supports the need for specific workplace accommodations, including telework, modified schedules, changes in work duties, or other adjustments.

Important: This service provides an independent medical opinion. It does not guarantee approval of a requested accommodation, determine whether an employer must provide a particular accommodation, or constitute legal representation.

Please complete the questions below so our team can assess whether your request falls within our physicians' scope of expertise.

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Legal name* This field is required.

First name

Last name

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Email address* This field is required.This information is requested only to communicate with you about your request. We will never sell your information, and will never use your email for any other type of communication.

example@example.com

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Phone number* This field is required.This information is requested only to communicate with you about your request. We will never sell your information, and will never use your phone number for any other type of communication.

Please enter a valid phone number.

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State or territory of residence * This field is required.

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Please provide city and country outside the US

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What best describes your reasonable accommodation request?* This field is required.

Accommodation for my current federal position

Accommodation for my current private-sector position

Accommodation during the federal hiring or application process

Accommodation for a position I have been offered

Other / Not sure

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Federal agency, department, or private-sector employer* This field is required.

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What is your current employment status?* This field is required.

Current federal employee

Federal job applicant

Federal employee currently on medical leave

Former federal employee

Private-sector employee

Other

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Your job title / role* This field is required.

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Brief description of essential job functions* This field is required.Please describe the core duties of your position.

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Do you have an official position description or other documentation identifying your essential job duties?

Yes

No

I can request this information

Not sure

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What medical condition(s) cause the functional limitations?* This field is required.List provider-diagnosed medical condition(s) only.

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How does your medical condition affect your ability to perform your job duties?* This field is required.Please describe any physical, cognitive, psychological, or other functional limitations related to your medical condition and how they affect your work. Examples might include difficulty concentrating, prolonged sitting or standing, lifting, maintaining a regular schedule, or performing certain tasks.

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Is the condition service-connected or related to military service?* This field is required.

Yes

No

I’m not sure

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Are these limitations:* This field is required.Choose one.

Temporary

Permanent

Episodic/variable

Not sure

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Do you have medical records documenting your condition and related functional limitations?

Yes

I have some, but they may be incomplete

No

I'm not sure

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Have you undergone any evaluation specifically assessing your functional abilities or work-related limitations?Examples include a Functional Capacity Evaluation, occupational therapy assessment, neuropsychological testing, or other functional assessment.

Yes

No

I'm not sure

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Treating physician(s)

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Requested accommodation(s)* This field is required.List the specific accommodation(s) requested (e.g., remote work, modified schedule, ergonomic equipment, duty modification).

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What is the current status of your accommodation request?* This field is required.

I have not submitted a request yet

My request is pending

My employer has requested additional medical documentation

My request was denied

My employer proposed an alternative accommodation

I am requesting continuation or modification of an existing accommodation

Other

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Did your employer provide a written explanation for the denial?

YESNO

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Which essential job duties or workplace activities are affected by your medical condition(s)?* This field is required.Please describe specific difficulties you experience in performing your duties. Examples may include prolonged sitting or standing, concentrating during extended meetings, maintaining a fixed work schedule, commuting when relevant to the requested accommodation, or performing physically demanding tasks.

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How would the requested accommodation help address your medical limitations at work?* This field is required.Please explain how the accommodation would help you perform your job duties or manage limitations related to your medical condition.

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Have you previously received workplace accommodations for your medical condition(s)?* This field is required.

Yes, I am currently receiving accommodations

Yes, I previously received accommodations

No

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If yes, what accommodations were provided, and were they effective?

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Who has requested medical documentation to support your accommodation request?* This field is required.

Human Resources or Reasonable Accommodation Coordinator

My supervisor or manager

Another agency or employer representative

No one yet — I am obtaining documentation proactively

Attorney

Other

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Has your employer or federal agency provided a medical documentation form, questionnaire, or written request describing the information needed?* This field is required.

Yes

No

Not yet

I'm not sure

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Does the agency require the physician to complete its specific form?

Yes

No

I'm not sure

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Does your employer or agency have a deadline for submitting medical documentation?* This field is required.

Yes

No

I'm not sure

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What is the submission deadline?

Date

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Has a Functional Capacity Evaluation (FCE) or similar assessment been completed?* This field is required.

YESNO

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Select service level* This field is required.Please visit our website at disabilitymedicalopinions.com or call 360-918-7201 for more details.

Standard Accommodation IMO

Comprehensive Accommodation IMO

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Medical records you plan to submitCheck all that apply.

Functional Capacity Evaluation (FCE)

Occupational therapy assessment

Neuropsychological testing

VA medical records

Private medical records

Imaging / lab reports

Request letter or email from agency/employer (if available)

Other

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Approximate number of pages you expect to submit* This field is required.Additional fees may apply for extensive record review. Please plan to submit only records relevant to this request; unrelated records may delay review.

Less than 25 pages

25-50 pages

More than 50 pages

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Acknowledgment of scope* This field is required.

I understand that this service provides an independent medical opinion based on available records.

I understand this is not advocacy, not legal advice, and does not guarantee approval of my accommodation request.

I understand that additional fees may apply for extensive record review.

I understand that this service provides an independent medical opinion only and does not establish a physician–patient relationship or provide medical treatment.

I understand that the physician will independently evaluate the available medical evidence and may determine that the requested accommodation is medically supported, that additional information is needed, or that the available evidence does not support the requested accommodation.

I understand that the physician's opinion may differ from the accommodation I am requesting and that payment does not guarantee a favorable medical conclusion.

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Additional information you believe is relevantOptional

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Please type your nameThis will serve as your e-signature.

First Name

Last Name

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Signature

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Date submitted(Today's date)

Date

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Please verify that you are human* This field is required.