I/EDR:10 2026

The document is a physical assessment form used by the Monroe County Department of Human Services to evaluate an individual's employability. It requires completion of various sections including client identification, medical history, current medications, and functional limitations. The form also includes an authorization for the release of medical information and outlines different levels of employability based on the client's condition. Medical professionals are required to complete and sign the form.

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Click ‘Get Form’ to open the I/EDR:10 in the editor.
Begin by filling in the 'Client Identification' section. Enter the client's name, address, DHS case number, last four digits of their SS#, and date of birth.
Complete the 'Authorization for Release of Medical Information' section by signing and dating where indicated. Ensure a witness also signs if required.
In the 'Employability' section, select the statement that best describes the client's condition. Provide details on reasonable accommodations if applicable.
Fill out the 'Chief Complaint(s)/History of Present Illness' and 'Medical Conditions' sections thoroughly, listing all relevant information.
Document current medications and any side effects experienced by the client in their respective fields.
Finally, ensure that a medical professional completes and signs the form, providing their information as required.

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