Individual Eligibility Evaluation Form

INSTRUCTIONS FOR INDIVIDUAL ELIGIBILITY EVALUATION (IEE) Form

General Instructions

Double clicking on the grey boxes will give you the choice to check or uncheck the box by changing the default setting.

The grey areas that say enter text here are text fields and are not size limited. They will expand as you enter text.

The tables are also not sized limited and each row will expand as you enter text.

You can add rows or columns to any of the tables by highlighting a full row or column, right clicking and selecting insert.

In the evaluator section the box that says click here to enter a date has a pull down calendar. You can just open the calendar and select the date.

Heading section

Determine if this is an initial or annual evaluation and check the appropriate box. For people who are blind only an annual evaluation is required.

Enter the name of the individual being evaluated. If the agency has multiple people with a common name, such as Joe Smith, ensure that there will not be any confusion understanding whose evaluation is whose (possibly by including nicknames or employee numbers). The listed name should also be easily matched with payroll data.

Employee number – Use of this field is optional. It is intended to assist those agencies that file using an employee number instead of a name.

I. Background Section

This section of the evaluation is to provide information on the individual that can be helpful in better understanding the individual.

Date of hire – Enter the most recent date of hire for the individual. If the individual has been employed at the agency in the past, include the periods of employment in the narrative.

Job Title – Enter the employee’s current job title. If the individual has changed jobs since the last evaluation information on the reasons for the change can be included in the narrative.

Job location/project – enter the location where the individual works. In some cases it may be more informative to list the project or product that the individual works on. For those that are involved with multiple locations or projects the individual’s primary job should be listed or a description such as mobile crew could be used.

Information considered pertinent to or supporting the evaluation – Include any information that helps in understanding the complete individual. Possible areas for inclusion included work history, current living situation, education, how he or she came to work for agency, productivity, supervisors comments and disciplinary actions. Much of this information could remain the same from year to year.

II. For People who are blind section

Since the Program’s requirement for people who are blind is the same whether he or she is employed at an NIB associated or NISH affiliated agency, this section is to be used in conducting the annual evaluation of any individual who is blind. One of the differences is that an initial evaluation is not required.

Medical Documentation – Indicate the type of documentation that you have for the individual. In general this will either be a document signed by a doctor stating the visual acuity or field of vision or a certification issued by a Federal, State or local governmental agency that specifies that the individual is legally blind.

Provide the name of the doctor or certifier and the date of the document. If both medical documentation and a certification are available provide both names.

Competitive employability– Indicate whether or not you believe that the individual is capable of competitive employment. The answer to this question does not affect the agency’s ability to count the individual’s hours towards the direct labor requirement. The hours worked by a person who is blind count towards the direct labor ratio whether the individual is considered competitively employable or not.

If individual is capable of competitive employment does he or she wish competitive placement – If you have determined that the individual is competitively employable you must then determine if the individual is interested in working for a commercial company.

If the individual wishes placement in a job in the community what steps are being taken to place the individual – If the individual is interested in working for a commercial company rather than remaining at your agency what steps are you taking to find the individual a job with a commercial company.

III. For people who are severely disabled

Medical Documentation – Indicate the type of documentation that you have for the individual. In general this will either be a document signed by a doctor, psychologist or psychiatrist or other individual qualified to make the diagnosis or a certification from a government agency that specifies the individual’s disabilities. However, for people with multiple disabilities documentation of both types might be present.

If the individual is taking medications for a disability and you know which medication is being taken for a disability that information can be entered by adding a line under the disability and list the medications.

Synopsis of Severe Disabilities – From the medical documentation that you have, fill out the table listing each severe disability, the name of the doctor or certifier and the date of the documentation. Some States allow qualified individuals other than doctors to make psychological evaluations; in such cases the name and title of the individual making the evaluation should be placed in the Doctor’s name column. Listing the date of the documentation will be helpful during future annual evaluations in considering whether the medical documentation should be updated. As noted in the general section, rows can be added if needed to list more disabilities.

Synopsis of functional limitations – Across the top of the table list each of the individual’s severe disabilities at the top of a column. Then for each listed disability consider the six major life functions and place an X in the appropriate row if you believe that the disability causes the individual to have impairments of that life function. The purpose of this section is to make you think of how each of the individual’s disabilities results in functional limitations for the individual. If needed, columns can be added to record the functional limitations of additional disabilities, but it is suggested that no more than two or three columns be added. Remember that many disabilities can cause multiple functional limitations, but that a specific individual may not exhibit all of the possible limitations. See below for definitions and some examples of each of the six functional limitations.

Competitive employability – Determine whether you believe the individual is currently capable of competitive employment and check the appropriate box. If the answer is no then complete the table providing a brief description of the individual’s functional limitations and the supports or accommodations that you are providing to make the individual successful. For some people it is the sum of many small supports and accommodations rather than one or two major supports or accommodations.

IV. Evaluator

The Commission’s regulations address the basic requirements of the individual signing the evaluation. For the evaluation of a person that is blind the evaluator must be an individual qualified by training and/or experience to make this determination. For the evaluation of a person with a severe disability the evaluator shall be a person or persons qualified by training and experience to evaluate the work potential, interests, aptitudes, and abilities of persons with disabilities

Enter the name and title of the individual performing the evaluation and the date that the evaluation is completed.

Enter the location of the evaluator or program for which the evaluator is responsible. For agencies with multiple locations and/or evaluators this can be extremely helpful in determining the extent of problems with evaluations.

The evaluator needs to sign the evaluation. Electronic signatures are acceptable.

Definitions

The Commission’s regulations define blind and severely disabled in section 1.3 (41CFR 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.

Severely disabled means a person other than a blind person who has a severe physical or mental impairment (a residual, limiting condition resulting from an injury, disease, or congenital defect) which so limits the person's functional capabilities (mobility, communication, self-care, self-direction, work tolerance or work skills) that the individual is unable to engage in normal competitive employment over an extended period of time.

(1) Capability for normal competitive employment shall be determined from information developed by an ongoing evaluation program conducted by or for the nonprofit agency and shall include as a minimum, a preadmission evaluation and a reevaluation at least annually of each individual's capability for normal competitive employment.

(2) A person with a severe mental or physical impairment who is able to engage in normal competitive employment because the impairment has been overcome or the condition has been substantially corrected is not “other severely handicapped” within the meaning of the definition.

Functional Limitations with Examples

The definitions should be the same or very similar to those used by the Vocational Rehabilitation Office in your state. The examples of under each functional limitation are exactly that, examples. There can be others. The website www.askJan.org is a excellent source for information on disabilities, functional limitations and accommodations.

Mobility – A person's ability to move to and from work or within a work environment, including walking, climbing, coordination, accessing and using transportation, use of spatial/perceptual relationships, and ability to perform physical functions and endure postural activities and physical environments

• Lifting & Carrying

• - Unable to lift/carry at least 10 pounds

• Sitting

• - Unable to sit for 60 minutes at a time

• Standing/Walking

• - Unable to stand/walk for 30 minutes at a time

• Climbing

• - Unable to climb stairs or ladders

• Stooping/Crouching

• - Unable to stoop or crouch

• Fingering (Fine Motor Manipulation)

• - Unable to perform fine finger manipulation

• Reaching (Gross Motor Function)

• - Unable to reach in all directions (including overhead)

• Environmental (Very Limited Ability to Tolerate the Following Work Environments)

  • Extreme Cold

  • Extreme Heat

  • Fumes, Odors, Dusts

  • Loud Noise

• Commuting

• - Unable to travel without assistance/attendant

• Spatial/Perceptual Relationships

• Severe limitation of depth perception

• Severe limitation in near acuity

• Severe limitation in distance acuity

• Severe limitation in field of vision

Communications – A person’s ability to transmit and/or receive information through spoken, written or other means. (effective exchange of information)

• Inability to acknowledge that information is understood

• Poor verbal communication skills / not intelligible

• Difficulty asking for help

• Difficulty expressing when hurt, sick or in pain

• Inability to follow simple written instructions

• Inability to follow simple verbal instructions

• Inability to hear

• Inability to ask or answer questions

• Difficulty interacting with fellow employees

Self-Care – The ability to perform activities of daily living, to participate in training or work-related activities, including eating, toileting, grooming, dressing, cooking, shopping, washing, housekeeping, money management and health and safety needs.

• Requires assistance in medical issues / administering medication

• Prone to self-injurious behaviors

• Inability to safely use tools and / or other utensils that will cause individual to hurt or harm oneself.

• Inability to manage bodily functions

• Inability to recognize environmental hazards.

•  Inability to live independently

• Requires community protection

• Inability to handle or understand finances / money

• Needs assistance / reminders / prompting with personal hygiene and dressing appropriately

Self-Direction – An individual's ability to independently plan, learn, reason, problem solve, memorize, initiate, organize, and make decisions. These processes allow individuals to assimilate information and learn specific skills related to job functions.

• Inability to make simple decisions

• Inability to cope with or solve problems

• Inability to remember sequence of tasks

• Easily Influenced, taken advantage of

• Inability to understand boundaries

• Inability to self-motivate

• Inability to get to work on time

• Lack of organizational skills

• Poor judgment

• Inability to understand consequences

• Lack of initiative to move from one task to another

• Easily confused

• Inability to work without supervision

• Need for extensive prompting

Work Skills – The ability to demonstrate specific tasks and work-related behaviors, to carry out job functions as well as the capacity to benefit from training necessary to obtain and maintain appropriate employment.

• Extensive job coaching needed to master the job

• Need for extensive re-training

• Requires pictorial aids / references

• Inability to do multi-step tasks

•  Inability to carry out previously learned tasks

• Inability to perform tasks in correct sequence

Work Tolerance – A person's capacity to meet the demands of the work place regardless of the work skills already possessed by the individual. Limitations may be due to physical disability, stamina/fatigue, effects of medication, or psychological factors.

• Inability to physically or emotionally withstand a work week

• Excessive absenteeism / poor attendance

• Frequent need for time off for therapy, hospitalizations

• Substandard work productivity

• Inability to tolerate distractions

• Frequent or long breaks needed 

• Easily distracted

• Easily overwhelmed

• Inconsistent work performance

• Difficulty accepting constructive criticism

• Inability to deal with changes (even small changes)

• Inability to Focus

• Issues with Stamina, Fatigue

U.S. AbilityOne Commission

1421 Jefferson Davis Highway, Jefferson Plaza 2,Suite 1080

Arlington, VA 22202-3259

(703)603-7740

info@abilityone.gov

www.abilityone.gov

The Committee for Purchase From People Who Are Blind or Severely Disabled operates as the U.S. AbilityOne Commission.