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COMMONWEALTH OF VIRGINIA

VIEW SNAP E&T

DEPARTMENT OF SOCIAL SERVICES

Participant’s Name: _____________ EMPLOYMENT SERVICES PROGRAM

Case #: ______________________

ESW: _______________________

ESW Phone #: ________________

MEDICAL EVALUATION It is our goal to assist the individual named below in becoming economically self-sufficient. This person states that they are unable to participate in employment and training activities. Please give careful consideration in completing this medical evaluation. The information that you provide will be used to determine program activities that this individual may be able to perform, even if there are some limitations.

ABILITY TO PARTICIPATE IN EMPLOYMENT AND TRAINING ACTIVITIES: 1. Date of examination on which this medical evaluation is based: (Examination must have been conducted within the last 90 days). 2. In terms of participating in employment and training activities and the individual’s current health issue(s), check the most appropriate statement (ONLY ONE) either A, B, or C.

A.

Able to participate in employment and training activities without significant limitations or modifications Skip the remaining questions and complete the Signature section at the bottom of page 2.

B.

Able to participate in employment and training activities at least 20 hours per week with limitations and/or modifications as needed. Anticipated number of months the limitation or need for modification will last. (check one) 1 2 3 4 5 6 7 8 9 10 11 12 How many total hours per week can the individual participate in employment and training activities? (check one)

20 25 30 35 Skip to page 2, answer questions 3 through 10, and complete the Signature section at the bottom of page 2.

C.

Not able to participate in employment and training activities in any capacity at this time Anticipated number of months the limitation or need for modification will last. (check one) 1 2 3 4 5 6 7 8 9 10 11 12 Skip to page 2, answer questions 3 through 10, and complete the Signature section at the bottom of page 2.

032-03-1040-11-eng (10/22)

(OVER)

Patient’s Name: ________________________________ Address: ______________________________________ _____________________________________________ Phone Number: ________________________________ Birthdate: _____________________________________ Agency Name: ________________________________ Address: _____________________________________ _____________________________________________ Agency Contact: ______________________________ Phone Number: _______________________________ Fax: _________________________________________ Email: