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 michelle.ballan@stonybrook.edu. Or go to Dr. Ballan’s Faculty Profile

These forms and the information therein is for general informational purposes only and should not be relied upon as a basis for any medical, legal or business decision. Any reliance placed on such information shall be at the user’s own risk.