Disability Questionnaire Please Note: Due to many frequent spam form submissions, we have added captchas to all of our forms. If you forget to fill out the captcha at the bottom of the form, just hit your browser's back button. This should take you back to the version of the form that had all the information filled out. You can then fill out the captcha at the bottom of the form. Also, you may always call us if you prefer.Your NameTelephone Number(s)Email AddressHome AddressCity, State, Zip CodeEmployerHow did you hear about us?phone bookanother attorneybar associationotherDisability QuestionnaireDisability is a term of art, and the definition varies from statute to statute. Social Security disability is not the same as Worker Compensation disability which is not the same as ADA disability. In fact, being eligible for one kind of disability could mean you're ineligible for another kind. The ADA, Sections 501, 503, and 504 of the Vocational Rehabilitation Act, and the New Mexico Human Rights Act basically use the same definition, but to understand these laws you must peel an onion. There are many layers of technical, technical definitions, and after awhile, the effort can make you cry. We have tried to use the phrasing and words from the ADA, but some of the words in the questionnaire are not used in their technical, precise sense in order to avoid confusion and the feeling that someone has turned on the fog machine.Where is the employer located and how many employees does the employer have?How has your employer treated you unfairly and when?Do you have a physical or mental condition/impairment?A physiological disorder, or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological, musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genito-urinary, hemic and lymphatic, skin, and endocrineA mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.Please briefly state or describe what physical or mental/emotional condition(s) you have.Does the condition affect your ability tocare for yourselfperform manual taskshearspeakbreathelearnwalkseesleepliftworkotherPlease DescribeDoes your conditionCompletely prevent you from doing any activity as the average person in the general population can perform?Significantly restrict you in the way, manner or duration you can perform any activity as compared to the way, manner, or duration under which the average person in the general population can perform that same activity?Neither of the aboveIf neither, please describe how the condition affects your ability to perform any activity.Please describe the nature and severity of the condition/impairment, the duration or expected duration of the condition/impairment, the permanent or long term impact, or the expected permanent or long term impact of or resulting from the condition/impairment.Who are all the doctors and other health care providers who have treated you for your condition/impairment? Please list names, general address (for example, Albuquerque), treatment (for example, surgery) and approximate dates of treatment (month or year is fine).Was your employer aware of your condition?NoYes, I told my employer orallyYes, I notified my employer in writingYes, I told other employees who told supervisor/employerYes, my employer askedIf you answered yes, when did your employer know?Could you perform the essential functions of your regular job with extra help, time off, additional breaks, light duty, transfer, or other accommodation?YesNoIf you could perform the essential functions of your regular job only with extra help, time off, additional breaks, light duty, transfer, or other accommodation, what accommodation or assistance was needed?If you asked your employer for help or an accommodation, what did you request, when and how (oral, written)?If you requested a transfer, was there an open or soon to open position available? If yes, what was position and how were you qualified to perform it?What was the employer's response to your request?If denied, what reason was given by employer? Was it in writing?Is there a union contract covering any group of employees?YesNoDoes the employer have an employee handbook or any document which discusses disabilities, leave, accommodations - including transfers or light duty, grievance procedures, or discipline?YesNoIf there were any witnesses to any of the things you've checked or written, who were they and what did they see or hear?DamagesWhat are your goals? What do you want to accomplish?What losses did you suffer?Briefly describe your efforts to find new work.Have you found other employment?YesNoIn addition to salary, if you have lost any fringe benefits such as health insurance or pension, please describe.The law requires that you must try to cut your losses by trying to get comparable work.If you are claiming that you were unlawfully denied a promotion, state the amount of increase and other benefits you would have gotten.If you were fired, and you have made any money (wages, contracts, etc) since, how much, when, and from whom?If you were fired and have been physically or mentally unable to work, please state the dates and reasons.If you have suffered any physical or emotional harm because of your employer's action, please describe the harm, any medical treatment (including therapy), the date of treatment, and the name and address of the treating professional (doctor, psychiatrist, psychologist, therapist, etc).Please add any other information you feel is important.
