Fillable EMPLOYEE DISABILITY CONSENT FORM with a disability for (WorkQuest)

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EMPLOYEE DISABILITY CONSENT FORM with a disability for (WorkQuest)

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PRINT NAME
CDF DATE
EMPLOYEE DISABILITY CONSENT FORM
CRP Name: ______________________________________
Employee/Client Number: ___________________________
I, ________________________________ have reviewed the CRP Disability Certification Form
completed by my employer dated ___________. I understand that I will be counted as person
with a disability for purposes related to the State Use Program and requirements under Chapter
122, Texas Human Resources Codes.
___________________________________________ ______________
SIGNATURE OF EMPLOYEE OR LEGAL REPRESENTATIVE DATE
If the authorization is signed by a Legal Representative of the Individual:
Printed name of Legal Representative: ________________________________________
Representative’s authority to act for the Individual: _______________________________
CRP Disability Certification Form must be included in the file with this document. This is a confidential
employee record of the CRP named above. The original copy is to be maintained at the CRP for review by the
Texas Workforce Commission or its designee.
Chapter 122, Texas Human Resources Code
40 Texas Administrative Code, Part 20, Chapter 806
Texas Workforce Commission, Rule 806.41(e)(2)
7/21/17
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EMPLOYEE DISABILITY CONSENT FORM with a disability for (WorkQuest)

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Completed 7 July 2021

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