COVID-19 Medical Information Request Form

For Medical Providers of Ouachita Baptist University Faculty and Staff

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To Ouachita Baptist University Faculty or Staff:

  • The Medical Information Request form is to be completed by the employee’s physician or health care provider.
  • Employees are to complete Section I below, provide details about the essential functions of their job to their medical provider and have the medical provider complete Section II.
  • Completed forms are to be returned to: Sherri Phelps by fax to: (870) 245-5408 or emailed to phelpss@obu.edu. For questions, please call (870) 245-5585.

 

Section I: To be completed by employee:

  • Release of Information: I hereby authorize the release of the following information to Ouachita Baptist University for the purpose of determining the availability of reasonable workplace accommodations. I further authorize Ouachita Baptist University to seek clarification of this documentation, if necessary, by contacting my physician or health care provider.

 

Section II:    To be completed by the physician or health care provider:

To Physician or Health Care Provider:

To initiate a request for reasonable accommodations, employees must provide current documentation of a disability. As the employee’s physician or healthcare provider, you are asked to fully complete all sections of this form. Additional information can be attached if necessary. Note: Federal and state law define a disability as a physical or mental impairment that substantially limits one or more major life activities, an individual having a record of such an impairment, or an individual being regarded as having such an impairment.

You should consider the employee’s job functions and other information relevant to the employee’s job at Ouachita Baptist University. If this information has not been provided, please contact the employee and let him or her know you cannot complete this form without that information.

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.

  • Thank you for your assistance in providing this information so that we may assess the employee's request.

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