Work/School Accommodation Recommendation Letter

[Practice/Clinic Name]
[Street Address]
[City, State ZIP]
Phone: [Main Phone Number] | Fax: [Fax Number] (Only include fax if applicable)

[Clinician Full Name], [Credentials] — Licensed in [State]
[Specialty] | [Clinic Email or Direct Phone]

Date: [Date of Letter]

[Recipient Name and Title / Office]
[Recipient Organization]
[Recipient Street Address]
[City, State ZIP] (Omit recipient address if unknown)

Re: [Patient Full Name], DOB [MM/DD/YYYY] — Accommodation Recommendations

Opening

[Patient Name] has authorized this communication for the purpose of accommodation planning. As the [treating clinician / independent evaluator] for [Patient Name], I have [treated the patient since (start date) / evaluated the patient on (evaluation date(s))]. My clinical opinions are based on [clinical visits and examinations / review of medical records / diagnostic testing] conducted within the scope of my practice. This letter focuses on functional limitations and recommended accommodations to support equitable access and safe participation; it is not a comprehensive medical record. [Diagnosis statement if disclosed with patient authorization, OR "Patient is under my care for a medical condition that results in functional limitations described below."]

Functional Impact Summary

Based on the above sources, the patient's functional profile includes the following limitations relevant to [work / school / testing] demands:

• [Functional domain (e.g., sustained attention, mobility, lifting capacity, stamina, fine motor coordination, sensory tolerance, sleep regulation)] — [mild / moderate / severe] severity with [continuous / episodic / variable] pattern. Affects: [specific task or demand]. [Evidence qualifier: "Patient reports..." / "On examination..." / "Based on [evaluation type] dated [date]..."] (Include brief objective support when available; omit raw scores and detailed test data.)
• (Repeat for each distinct functional limitation. Group closely related limitations into one bullet when appropriate.)

Accommodation Recommendations

(Link each recommendation to the corresponding functional limitation and affected demand. Provide options rather than mandates. Distinguish restrictions from accommodations.)

• Because of [specific limitation] affecting [work/school/testing demand], recommended options include: (a) [accommodation option], (b) [accommodation option]. Rationale: [brief explanation of how the accommodation mitigates the barrier]. Restrictions: [activities to avoid or limit] (Only include if clinically necessary.) Status: [temporary trial through (date) / ongoing with reassessment on (date)].
• (Add additional bullets for each limitation-to-accommodation mapping.)

Duration & Reassessment

Effective start: [MM/DD/YYYY]. Anticipated duration: [through (specific date) / trial period with reassessment on (specific date) / duration uncertain; recommend reassessment in (timeframe)]. Reassessment plan: [follow-up interval and conditions for earlier review, such as symptom change, task modifications, or new clinical information].

Closing

Please contact my office with targeted functional questions or to discuss alternative accommodations within the scope of the patient's authorization. This letter provides clinical information to support accommodation planning; final accommodation determinations rest with the [employer / school].

Respectfully,

______________________________
[Clinician Signature]
[Clinician Printed Name], [Credentials]
[License Type and Number], [State of Licensure]
[Specialty]
[Practice/Clinic Name] | Phone: [Phone] | Fax: [Fax] (Omit fax if not applicable)