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VIRGINIA DEPARTMENT OF SOCIAL SERVICES SNAP E&T Medical Evaluation
10/24 VOLUME V, PART XXV, APPENDIX II, PAGE 39
MEDICAL EVALUATION
FORM NUMBER – 032-03-1040
PURPOSE OF FORM – To provide medical information concerning the mental/physical condition of a Temporary Assistance for Needy Families (TANF) and/or SNAP Employment and Training (SNAP E&T) applicant/recipient or a Virginia Initiative for Education and Work (VIEW) participant.
USE OF FORM – To be used by the local social services agency in securing medical information when a written statement is necessary to determine ability to participate in employment and training activities.
NUMBER OF COPIES – One.
DISPOSITION OF FORM – Submitted to the examining or treating medical professional and, upon return to the local department, filed in the case record.
INSTRUCTIONS FOR PERPARATION OF FORM – The information at the top of the form is completed by the eligibility/VIEW/SNAP E&T worker prior to submittal of the form to the examining or treating medical professional. The information requested in Items 1 through 10 is entered by the examining or treating medical professional. The medical doctor, physician’s assistant, or nurse practitioner is to sign the form and also complete the identifying information in the appropriate spaces.
In the case of a single parent household, if the medical professional completing the form indicates in Compliance, item 9, that the patient’s condition hinders his/her ability to care for the children, contact the agency’s childcare and/or child welfare staff to determine if services are needed
TRANSMITTAL #35