Please explain nature of impairment
I understand that I am required to submit pertinent documentation from my healthcare provider(s) regarding my
impairment(s). Please submit your documentation to George Jackson, MD or Associates, by fax to (919) 681-0555, or mail to P.O. Box 3148, DUMC, Durham, NC 27710.
I have completed the release of information giving Duke permission to consult with my health care professional(s) as necessary to determine that I am a qualified employee with a disability, to seek guidance as to any functional limitations resulting from my condition(s) and to assist the University in determining what appropriate accommodations may exist to address my limitations.
I voluntarily give Duke University permission to contact the following doctor(s), as necessary, for discussion of my case as it relates to possible limitations of a major life activity, which can affect my employment. I have been given the opportunity to ask questions regarding this form and to have those questions answered to my satisfaction. I further understand that all information obtained from this interaction will be maintained and used in accordance with applicable confidentiality requirement.
Requesting Provider: George Jackson, MD or Associates
Phone Number: (919) 684-3136
Address: P.O. Box 3148, DUMC, Durham, NC 27710
By clicking on the submit button, I hereby give Duke University, including but not limited to, EOHW, DMS, HR, E&O, FMD, Fire and Safety and my work unit, permission to explore possible coverage and reasonable accommodations under the American with Disabilities Act and the ADA Amendments Act. I understand that all information obtained during this process will be maintained and used in accordance with applicable confidentiality requirements.