Disability Form

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This field is for validation purposes and should be left unchanged.

Under ADA, major life activities refer to essential functions or tasks that are significant to daily life. A person is considered to have a disability if a physical or mental impairment substantially limits one or more of the below activities.

FOR THOSE THAT APPLY TO YOU SELECT THE FUNCTIONS THAT ARE IMPAIRED:

Please list the accommodations needed

Please list other bodily function affected.

Other activities or functions affected

If you selected ‘other’ above and need to explain further, do so here:

Disability Information

Disability form title

Which NCF doctor are you requesting to review your disability evaluation?

Date disabilty began

Date diagnosis was made

Diagnosis for disability

Date part-time work began

What is your current job title, description, and necessary duties?

What functions of your job are you unable to complete due to your condition or disability?

Which symptoms of your condition are preventing or restricting your ability to perform the duties of your job?

Disability Packet

Disability Information