Healthcare Provider Request for Information (RFI) Form

Please return completed form to Amazon Disability & Leave Services (DLS).
Employees: upload to MyHR - Accommodations
Providers: Fax to 1-855-579-1799 or email to amazondls@amazon.com

Employee Portion
Name: Sara Orozco
Amazon Alias: Amazon Associates - Oromsara
Date of Birth: 02-15-2003

I authorize my healthcare provider completing this form, and my healthcare provider’s agents
and associates, to release medical information about me to Amazon, as needed to enable
Amazon to evaluate whether and how my medical condition impacts my ability to perform my
job duties and to further evaluate accommodations at work. This authorization covers
subsequent requests by Amazon for clarifying and obtaining additional information relevant to
these subjects. I understand this authorization may expire under the laws of some states after I
sign it, but I agree to extend my authorization as needed for these purposes.
Signature of Employee or Representative Sara Orozco
Relationship to Employee (if signed by representative) Not Applicable
Date Signed 09-08-2023
Healthcare Provider Portion
Below information to be completed by Healthcare Provider or their office only.
For purposes of this form, the “employee” referenced throughout refers to your patient (name,
date of birth above), who has requested reasonable accommodation related to their workplace
or employment. The intent of this form is to establish that this employee has a qualifying
disability or medical condition, and to identify restrictions and/or limitations needed to
evaluate the employee’s request. This medical documentation should describe the nature,
severity, and duration of the impairment, the activity/activities that the impairment limits, and
the extent to which the impairment limit’s the employee’s ability to perform the
activity/activities and should substantiate why the requested reasonable accommodation is
needed. Please complete all applicable portions of the form. If information is incomplete,
Amazon will likely need to contact your office to complete the form.

Section 1: Medical Condition

In this section, please provide information about the medical condition(s) that may impact the
employee’s ability to perform their job or that otherwise related to their employment.
Diagnosis is not required unless the underlying condition is pregnancy related 1, but diagnosis
can be helpful in the interactive reasonable accommodation process.

1 The Pregnancy Workers Fairness Act (PWFA) is a federal law that applies specifically to accommodation for
pregnancy-related conditions. In order to determine whether this law applies, Amazon needs to know if the
accommodation request is due to a pregnancy-related condition.
Return completed form to Amazon (DLS).
Employees: upload to MyHR - Accommodations. Providers: fax to 1-855-579-1799.
Does the employee have a disability or medical condition that impacts their work?
☐Yes (provide details below).
✔️No. If you answer no, please explain how this accommodation request is connected to
the employee’s employment.

The patient has received a trauma in her tailbone in results of it being injury with prolonged
pain.

Is this request related to pregnancy or childbirth?

☐Yes
✔️No

Major Life Activities Impacted

☐Sensory: Vision; Hearing; Speech; Other Sensory
☐Executive Functioning/Neurodiverse: Concentration; Learning; Comprehension; Communication;
Sensory; Other Executive Functioning
✔️Mobility: Gross Motor/Sitting Standing, Walking, Lifting; Fine Motor/Dexterity; Other Mobility
☐Medical: Immunocompromised; Medical Device; Personal Medical Treatment Administration;
Other Medical
☐Mental Health: Social Settings or Interactions; Interactions/Written, Verbal, Other; Sensory or
Other Triggers; Other Mental Health
☐Other (describe major life activities impacted): Click or tap here to enter text.

Describe whether and how the medical condition(s) above substantially impact major life activities:

Patient has a history of a tailbone injury, caused by falling on it. There is no brokerage but
due to trauma it resulted in persistent pain when overused.

Section 2: Restrictions and Limitations

Describe the employee’s job-related restrictions/limitations (e.g. cannot stand for more than X hours,
cannot engage in repetitive motion, distracted by noisy environments, lighting sensitivity). Please also
explain specifically how the restrictions/limitations impact the employee’s ability to perform their job
duties or otherwise meet job-related requirements. Please also identify the anticipated duration of the
restrictions/limitations, including start and end date.

As a result of her past injury she struggles with excessive use of ladders or picking up
excessive weight. Daily activities like stairs, walking, and standing are not affected.

Section 3: Accommodation Recommendation/Other Information

Amazon’s interactive accommodation process considers the job-related limitations of the
employee’s condition and needs of the business and role. While not required, we welcome
recommendations from healthcare providers on accommodations. Please use this section if
you have accommodations to recommend, or any other information you think we should
consider in evaluating reasonable accommodations for this employee.

Return completed form to Amazon (DLS).

Employees: upload to MyHR - Accommodations. Providers: fax to 1-855-579-1799.
Employee is comfortable working in their department and position, and that she works
successfully with no pain to her prolonged injury.

☐Assistive technology or alternate formats (e.g. screen reader software, enlarged monitor,
speech to text software, push pads for doors, alternate keyboard or mouse). Please
describe:Click or tap here to enter text.
☐Additional training (self or manager), temporary job coach, or other individualized
support.
☐Changes to work duration/time/schedule:
☐Specific shift/scheduling flexibility/reduced time. Please describe specifically:Click
or tap here to enter text.
☐Additional breaks. Please describe frequency and duration:Click or tap here to
enter text.
☐No Overtime (hourly employees only)
☐No shift bid (hourly employees only)
☐Other. Please describe: Describe other Click or tap here to enter text.
☐Changes to work environment (work location or workstation set up). Please describe:Click
or tap here to enter text.

✔️Changes to job functions.

✔️Carrying/Lifting. Please describe in specifics (maxiumum amount of time in hours
and maximum amount of weight) : Straining begins to be present when lifting 30 lbs
☐Push/Pull. Please describe in specifics (maxiumum amount of time in hours and
maximum amount of weight) :Click or tap here to enter text.
☐Squatting/Bending. Please describe in specifics (maxiumum amount of time in
hours) :Click or tap here to enter text.
✔️Climbing (e.g. use of ladder or # of stairs/steps). Please describe in specifics
(maximum amount of time in hours) : Recommend to be avoid of ladder usage stiff
and tenderness

☐Sitting. Please describe in specifics (maxiumum amount of time in) :Click or tap
here to enter text.
☐Standing. Please describe in specifics (maxiumum amount of time in hours) :Click
or tap here to enter text.
☐Reaching/Gripping. Please describe in specifics (maxiumum amount of time in
hours) :Click or tap here to enter text.
☐ Other. Please describe:Click or tap here to enter text.
☐Changes to equipment operation.
☐Power Equipment (e.g. forklift, reach truck, scissor lift, etc.). Please describe the
specific limitation :Click or tap here to enter text.

Return completed form to Amazon (DLS).

Employees: upload to MyHR - Accommodations. Providers: fax to 1-855-579-1799.
 ☐Vehicles (e.g. van, truck). Please describe in specifics (maxiumum amount of time
in hours and maximum amount of weight) :Click or tap here to enter text.
☐Working from heights. Please describe in specifics (maxiumum amount of time in
hours and maximum height) :Click or tap here to enter text.
☐Other. Please describe: Click or tap here to enter text.
☐Other changes.
☐Working in extreme temperatures (e.g. freezer). Please describe the specific
limitation :Click or tap here to enter text.
☐Safety Equipement (e.g. safety shoe, gloves, other). Please describe in
specifics. :Click or tap here to enter text.
☐Other Please describe in specifics: Click or tap here to enter text.

Section 6: Healthcare Provider Signature and Contact Information*

Healthcare Provider Name/Title: Humberto Rodriguez
Specialty: Emergency Medicine Physician Address:4670 S Fort Apache Rd, #130, Las Vegas, NV
89147
Phone: 702-552-1818
Fax: 702-968-8637
Signature: Humberto Rodriguez
Date of Evaluation: 09-08-2023

Return completed form to Amazon (DLS).

Employees: upload to MyHR - Accommodations. Providers: fax to 1-855-579-1799.