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Disability Report Form Guide (Adults)

Disability Report Form Guide (Adults)

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Section 2 - Your Illnesses, Injuries or Conditions and How They Affect You

  General Information About Section 2
A. What are the illnesses, injuries or conditions that limit your ability to work?
B.
How do your illnesses, injuries or conditions limit your ability to work?
C. Do your illnesses, injuries, or conditions cause you pain or other symptoms?
D. When did your illnesses, injuries or conditions first interfere with your ability to work?
E. When did you become unable to work because of your illnesses, injuries or conditions?
F. Have you ever worked?
G. Did you work at any time after the date your illnesses, injuries or conditions first interfered with your ability to work?
H. If you did work after the date your illnesses, injuries, or conditions first interfered with your ability to work, did they cause you to work fewer hours, change your job duties, or make any other job-related changes?
I. Are you working now? If No, when was the last day you worked?
J. Why did you stop working?

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Last reviewed or modified Wednesday Apr 09, 2008
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