Disability Compliance Assessments

D.C.A.

Disability Compliance Assessment

The following form has been developed as part of our Disability Compliance Assessment (D.C.A.) service, which provides an initial consultation of disability compliance situations. Complete this form and provide our office with available supporting documents. Feel free to call us at 877-984-7969 or email us at referral(at)R2WP(dot)com or fax us at 877-984-9901

Not workingWorking in regular JobWorking in modified job, (regular job with reasonable accommodations in place)Working in alternate job, (completely different job, unable to safely perform regular job with or without reasonable accommodations)Working full-timeWorking part-time / Modified work scheduleTemporarily totally disabledOn leave of absenceWorking part-time

Date last worked:

Other

Employee's request for reasonable accommodationEmployer's knowledge of work restrictionsNon-industrial related / Employee's own medical conditionTemporary work restrictionsPermanent work restrictions resulting from an industrial claimNew additional work restrictionsWork restrictions, have been updatedFollow up meetings, address accommodations currently in placeReturn to regular work / Release to full duty

Other

Copy of all available work restrictions.Provide work restrictions from agreed medical examiners, qualified medial examiners, primary treating physicians, as outlined in all medical notes.Current job description of employee's regular job.Summary of prior interactive meetings / discussion with employee.Summary of current reasonable accommodations in place.Permanent work restrictions.Temporary work restrictions.

D.C.A. Disability Compliance Assessment The following form has been developed as part of our Disability Compliance Assessment (D.C.A.) service, which provides a

2201 East Willow Street, Suite D #189
Signal Hill
CA
90755
United States