Disability Intake Form

Please complete the General Intake Questionnaire before completing this form.

Note that required fields are marked with an asterisk. The form cannot be submitted unless all required fields are filled in. You may also download a printable PDF file of this form for mail submission. This file requires the free Adobe Reader.

Your Contact Information

Name: (First) * (Middle Initial) (Last) *

Street Address *

City *

State *

Zip *

County *

Home Phone *

Cell Phone

Work Phone

Email Address

1. What is your disability? *

2. How does your disability affect you? (Check all that apply.) *

a. Walking

b. Spe aking

c. Seeing

d. Breathing

e. Hearing

f. Caring for self

g. Other (Please describe)

h. Working (Please describe)

3. Do you have a record of disability? *

4. Are you regarded as having a disability? *

5. Do you have the required skills, experience, education and other job-related requirements of the job named in your complaint? *

Please list skill needed and your qualifications. *

6. What are the essential functions of the job? *

7. Is reasonable accommodation an issue? *

8. Did you request a reasonable accommodation? *

Explain what kind of accommodation was requested and when. What was said and by whom?

Explain whether you rejected any proposed accommodation, and the reason(s) for your rejection.

9. What was said or done to you to make you feel the employer had a problem with your disability? Include a description of all verbal or written statements or documents. Include specifics as to person(s) who made such statements, what was said, and names of witnesses (if any). *

COMMISSION INFORMATION

Disability Intake Form