The following form has been developed as part of our Disability Compliance Assessment (DCA) service, which provides clients with a cost effective initial assessment of disability compliance matters in their organization. If your organization has not already signed up for this service then you will be contacted to discuss terms of service and fees.

Please complete the following and fax or email over all pertinent supporting documents available.

Date:    Employee Name: Job Title: Type of Disability: Industrial Related     Non-Industrial Related Date of Injury/Disabling Condition: Name & Title of person completing form: Phone Number: Email: 1. What action initiated the need for a Reasonable Accommodation Meeting? Request by employee     Knowledge of work restrictions     Perception of Need      Other - if other, please explain   2. What stage are you in the Interactive Process? No prior meetings     Already met with employee 3. Has the employee reached Maximum Medical Improvement /Permanent & Stationary Status? Yes     No     N/A 4. What is the employee's current employment status? Working in regular job     Light Duty     On Leave (return date):            If On Leave: Paid    Unpaid     Other - if other, please explain   5. What medical reports / documents / evidence do you have to support the need for an Interactive Meeting? Permanent Work Restrictions from claims file     Note from employee's treating physician     None 6. Does a current job analysis outlining all essential job functions and physical demands exist? (* If yes, please provide copy of job analysis, if not provide a copy of job description.) Yes     No 7. What accommodations, if any, have been provided? Provide as much detail as possible or provide copies of past process documents.    Upon completion, please forward all supporting documents to DCA@gortw.com or by fax to the Monjaras & Wismeyer Group at 877.984.9901. Upon receipt you will be notified of the consultant assigned to work on your file. Please enter the security code you see above: