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INDIVIDUAL ELIGIBILITY EVALUATION

Disability Qualification Determination
Directions: Complete this form to determine eligibility as a qualified direct labor employee whose
work will be counted as hours performed by a blind or significantly disabled individual as
required by U.S. AbilityOne Commission Compliance Policy 51.403.
Type of Disability review: Initial ☐ Annual ☐
☐ Permanent Disability(ies) (One-time submission)
☐ Non-Permanent Disability(ies) (7-year review)

*Permanent Disability is defined as: A significant physical or mental disability that is not expected to
substantially improve during an individual’s lifetime.

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Form Reference Number: [The form reference number is randomly generated by the NPA and is
submitted into the CNA’s electronic data base with the information on this form. The employee’s name
associated with the form reference number and any medical documentation concerning the employee are
maintained solely by the NPA. The CNA will receive such identifiable information regarding the employee
during an oversight visit if this form is reviewed by the CNA.]

____________________________________________
Name: Click here to enter text.

Employee Number: Click here to enter text.

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I. Background Information

Date of Employee’s Hire:

Click here to enter text.

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Date of Employee’s Eligibility Determination (if different from date of hire): Current Job
Title: Click here to enter text.
Nonprofit Agency (NPA) Name: Current Job Location/Project: Click here to enter text.

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Information considered pertinent to or supporting the evaluation:

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Click here to enter text.

II

Section A. For people who are blind

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Medical Documentation
Signed eye exam with person’s visual acuity or field of vision specified ☐
Signed letter from Government Agency stating that individual is blind

☐

The individual is blind as defined in 41 CFR 51-1.3. Blind means an individual or class
of individuals whose central visual acuity does not exceed 20/200 in the better eye with
correcting lenses or whose visual acuity, if better than 20/200, is accompanied by a limit
to the field of vision in the better eye to such a degree that its widest diameter subtends
an angle no greater than 20 degrees.)
☐Yes - Complete the Section A information below, then proceed to Section G.

Doctor’s Name

Date of Document

Certifier’s Name

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Competitive employability

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Is this individual currently capable of competitive employment?

Yes ☐ No ☐

If yes, does he or she desire to be placed in competitive employment?

Yes ☐ No ☐

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If the individual wishes placement in a job in the community what steps are being taken to place
the individual: Click here to enter text.

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III. For people who are severely disabled

Medical ☐No (Proceed to Section B)

Section B. Individuals with Government Documentation Establishing Full
Eligibility
The Documentation is signed by physician, psychiatrist, or psychologist
☐

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Signed letter from Government Agency stating the individual’s diagnoses ☐

Synopsis of severe disabilities (This individual has the following disabilities)is receiving or is

eligible for:

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☐SSI (based on disability)
☐SSDI
☐Medicaid (based on disability)
Disability

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Doctor’s Name

Certifier’s Name

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Synopsis of functional limitations (This individual has the following limitations in self-care, selfdirection, work skills, work tolerance, communication and or mobility as a direct result of the
documented impairment)

Note: This government documentation does not need to identify the individual’s
specific disability. The individual’s disability will be identified in the annual Participating
Employee Information Form. The documentation also does not need to be signed by a
government official.
If any of the above three certifications are selected, proceed to Section G.
☐ The individual is not receiving or eligible for any of the benefits listed above
(Proceed to Section C).
Section C. Individuals with Other Government Documentation
The individual is receiving or is eligible for:
☐Vocational Rehabilitation Services
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☐Veterans’ benefits based on disability/ Veteran Readiness & Employment Services
☐State Developmental Disability Services
☐Other Federal, State, or Local Disability Certification
☐School-to-Work transition services from educational systems for individuals over the
age of 18.
☐IEP, due to a permanent or temporary disability(ies), within 5 years of graduation/exit
from school.
Date of Document

Impaired Major Life
Function

Disabilities (list individual disabilities)
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Mobility
Communication
Self-Care
Self-Direction
Work Tolerance
Work Skills

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If any of the above are selected, proceed to Section E.

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☐TheCompetitive employability

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Is this individual currently capable of competitive employment (obtaining and maintaining a job
without supports from the nonprofit agency)?

YES ☐

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NO ☐

is not receiving any of If the answer above is no, detail the individual’s functional limitations
noted above and what accommodations or supports not normally provided in typical community
employment are being provided:(Proceed to Section D)

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Section D. Individuals with Medical Documentation
The individual has been diagnosed by a qualified licensed professional to have a
disability.

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☐Yes (Proceed to Section E.)
☐No

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Functional LimitationQualified Licensed

Professional’s Name

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and
Accommodations
Functional Limitation DetailsDate of Formatted:Supports
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Document

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Mobility
Communications
Self-Care
Self-Direction
Work Tolerance
Work Skills

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If “No” is selected above, and documentation was not provided in sections A, B, or C,
the individual is not eligible to be counted in the ODLH ratio as blind or significantly
disabled.
Section E. Significant Job Supports – complete for individuals whose
documentation is covered in Sections C or D above.
Significant job support(s) are defined in Commission Policy 51.403 as: One or more
accommodation(s) or adaptation(s) needed by an individual with a physical or mental
disability and that may be extensive and ongoing in order for that individual to be
successful in the job position.
Which significant job support(s) does this individual need to overcome barriers to
competitive employment, as a result of the individual’s disability(ies)?
☐ Access/Assistive Technology: Devices or software to aid communication
(e.g., screen readers, voice recognition software, screen magnifiers)
☐ Adaptive Equipment: specialized tools or equipment to assist with tasks associated
with daily living
☐ Additional and/or enhanced training to meet essential job functions
☐ ASL Interpreter
☐ Emotion regulation and coping skill support
(e.g., for individuals with mood disorders or autism)
☐ Enhanced supervisory support and/or modified duties
(e.g., for people with intellectual/developmental disabilities)
☐ Job Coaching
☐ Medical accommodations: reduced/modified schedule to provide extra breaks or
significant time for medical administration
☐ Modified essential job functions
☐ Personal Care Attendants or Aides
☐ Ramps, automatic door openers, or other significant physical modifications
(e.g., for people using mobility devices or individuals with musculoskeletal
disabilities)
☐ Reader/Scribe
☐ Reduced qualitative or quantitative performance standards

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Narrative: How often are the above job support(s) needed and why are they
necessary?
IV. Evaluator
date.

Date: Click here to enter a

Name: Click here to enter text.

☐ Other Significant Job Supports
If other significant job supports are provided, in sufficient detail describe the job support
(s) provided, why the job support(s) are necessary and why they are extensive and/or
ongoing. Click here to enter text.

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Title: Click here to enter text.

Section F. Attestation
The evaluator has read U.S. AbilityOne Commission Policy 51.403, has reviewed the
supporting documentation of eligibility required by this form, and has confirmed that the
direct labor employee meets the eligibility standards for an individual who is blind or has
a significant disability as set forth in Policy 51.403.
Section G. Evaluator
Date of Determination: Click here to enter a date.
Location/Program: Click here to enter text.

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Name: Click here to enter text.
Signature:

Title:

Click here to enter text.

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TO BE COMPLETED BY CNA/U.S. ABILITYONE COMMISSION – COMPLIANCE
INSPECTION
Date: Click here to enter a date.
CNA/Commission: Click here to enter text.
Name: Click here to enter text.
Title: Click here to enter text.
Signature:
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