DLR – RA 203 REV 07/2019
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
REEMPLOYMENT ASSISTANCE DIVISION
420 S. Roosevelt St., PO Box 4730, Aberdeen, SD 57402-4730
Tel: 605.626.2452 Fax: 605.626.3172 dlr.sd.gov/ra
MEDICAL STATEMENT OF ABILITY TO WORK
PART I: CLAIMANT
Instructions: Complete Part I of this form and give to your physician to complete Part II. Any alterations or changes to the information
below must be initialed by your physician or may void this document.
Name: Date of Birth:
Last four of SSN:
Most recent employer: Position held:
Recently sought medical care for (symptoms, illness, injury):
Name of physician:
I am able to work at this time: Yes No
If you feel you are physically able to work, list the types occupations you will be seeking for work:
RELEASE OF INFORMATION
I hereby consent with my signature below to the release of information from my doctor or medical provider to the
Reemployment Assistance (RA) Division for the confidential use of that agency in determining my eligibility for RA benefits.
Claimant Signature: ______________________________________ Date:____/____/_______
PART II: PHYSICIAN
Instructions: The information requested below will enable the RA Division to make an eligibility determination for RA benefits for the
individual named above. Your cooperation in providing this information will be appreciated. This information may be provided to the
patient. Please FAX or MAIL this completed form within the next five days to the address at the top of the form. Thank you for your
assistance. (Please note: DLR is not responsible for fees or charges for completing this document).
Nature of CONDITION, ILLNESS, OR INJURY:___________________________________ Date began:_______________
1. On what date did you first examine this individual for this condition/illness/injury? Date: __________________
2. Most recent examination for this condition/illness/injury? Date: __________________
3. Is continued employment in the most recent employer/position listed above hazardous to this individual’s
health? Yes No
4. Did you advise this individual that this employment was a health hazard, or that he/she should leave this
employment? Yes No
If yes, when did you advise this individual that the employment was a health hazard? Date: ___________________
5. At the present time is this individual physically able to work in the occupation(s) listed above? Yes No
6. When was/will the individual physically able to do this work: Date: ___________________
7. Please describe restrictions/limitations to claimant’s present ability to work:
Physician’s Signature:____________________________ Date: ____/____/_______ Degree/Title:___________________
Clinic Address: ______________________________________ Tel: (_____) _____ - _______Fax: (_____) _____ - _______
Name of additional contact in your office regarding this information: __________________________________________
