CRP DISABILITY CERTIFICATION FORM
1. CRP Name:
6. Position Held and Brief Summary of Work Performed:
7. Referral or Evaluation Source:
8. CRP Supporting Documentation of Disability or Impairment on file:
2. Employee/Client Number:
3.
4. Entry/Hire Date: 5. Termination Date:
Full Time Part Time (less than 20 hours per week)
Medical Doctor Evaluation Form
Psychiatrist Evaluation Form
Psychologist Evaluation Form
Ophthalmologist Examination Form
Optometrist Examination Form
Proof of Social Security Disability Insurance (SSDI) Benefit
AbilityOne/JWOD Evaluation Form
Other Professional Evaluation Form
9. Documentation of Disability: Indicate below how this employee/client qualifies for
participation in the State Use Program.
Referral from any of the sources in Item 7a above (with documentation on file) implies that
the referral source listed made the determination that the disability impedes the individual
from maintaining gainful employment.
Disability determination from a Vocational Rehabilitation Specialist in Item 7b above must
include a completed Disability Determination Worksheet (DDW) indicating that the
disability impedes the individual from maintaining gainful employment.
Disability determination from a recognized licensed professional or other source in Item 7c
above should include the professional’s determination that the disability impedes the
individual from maintaining gainful employment.
I certify that to the best of my knowledge the information furnished on this form is accurate. I
understand and acknowledge that the above representations are material and important and will
be relied upon by the State of Texas in awarding State Use contracts.
Signature of CRP Director or Designee
Print Name and Title
Date
(assign a case number to each employee/client if none exists)
a. State, governmental or local social service agency (specify agency):
c. Other referral source (specify type of documentation by completing Item 8 below)
b. Vocational Rehabilitation Specialist (must complete accompanying Disability Determination
Worksheet - DDW)
CRP DCF 7/21/17
Chapter 122, Texas Human Resources Code
40 Texas Administrative Code, Part 20, Chapter 806
Texas Workforce Commission, Rule 806.41(e)(2)
Employee Disability Consent Form must be included in the file with this document. Attach
additional pages if necessary. 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.
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