Source: Disability COVID-19 Forms
Click on the name of your state below to download a COVID-19 Disability Form to complete online and print.
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
With a strong research focus on reducing healthcare barriers for individuals with intellectual/developmental disabilities (IDD), I wanted to help our friends, family members and clients receive quality medical treatment regarding COVID-19 symptoms, should this become necessary. Most hospitals are not allowing staff or loved ones to accompany patients for treatment. After learning of incidents of inferior treatment for individuals with IDD in New York hospitals, I created the COVID-19 Disability Form which has been reviewed by ER physicians, families of individuals with IDD and adults with IDD. At the request of disability agencies nationwide, the form was amended for each state governmental agency’s Developmental Disabilities Services and the state’s equivalent of the MOLST/POLST. The goal is for the form to be completed proactively prior to seeking medical attention for COVID-19 symptoms at a hospital. Having this form, and the accompanying documents noted on page 2 of the form, will help to alert ER staff to the preferred communication with the patient with IDD and his/her needs and wishes. My hope is that everyone completes this form and never needs to use it. If you share, post or cite this form, please use the reference Ballan, M. & Perri, C. (2020). COVID-19 Disability Form. Stony Brook, NY: NY. If you have questions, please contact Michelle Ballan, PhD at firstname.lastname@example.org. Or go to Dr. Ballan’s Faculty Profile