Third-Party Disability Assessment Form
Please complete this assessment based on your observations of the individual's functional abilities and challenges. Only provide information you have directly observed.
Your Name
*
First Name
Last Name
Relationship to the Individual
*
Please Select
Family Member
Friend
Caregiver
Educator
Health Professional
Other
Context of Your Observations
*
At home
At school
At work
In the community
Other
Functional Impact Assessment
*
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Mobility (moving around)
1
2
3
4
Communication
5
6
7
8
Self-care
9
10
11
12
Social interaction
13
14
15
16
Learning/understanding
17
18
19
20
Managing daily tasks
21
22
23
24
Overall Functional Impact
*
No Impact
1
2
3
4
Severe Impact
5
1 is No Impact, 5 is Severe Impact
Observed Strengths
Observed Challenges
Frequency of Noted Difficulties
*
Rarely
Sometimes
Often
Almost always
Duration of Your Observations (e.g., weeks, months, years)
*
Please Select
Less than 1 month
1 - 6 months
6 - 12 months
More than 1 year
Additional Comments (optional)
Submit Assessment
Should be Empty: