During this COVID-19 public health crisis, we wanted to share with you an informational form created by Michelle Ballan, PhD, Professor, School of Social Welfare & Family, Population and Preventive Medicine Stony Brook University to collect and summarize vital information about an individual that can be provided to the care team in the hospital. Please click below to access this fillable disability form for your completion.

This form was developed in conjunction with Emergency Room (ER) and hospital physicians, individuals with Intellectual and/or Developmental Disabilities (I/DD) and parent advocates. It is designed to be an informational support tool for individuals with I/DD who may need to go to the ER or be hospitalized due to symptoms of COVID-19.

Please keep the following information in mind:

  • Although this form is optional, we encourage people with I/DD to complete this information proactively in case it is ever needed.

  • In the event someone needs to go to the ER/Hospital, this form will help to alert ER/Hospital physicians and medical staff to the best ways to communicate with the person according to their needs and wishes.  

  • There are questions at the end of the form that ask about different types of medical treatment. These questions can be discussed with a trusted physician with whom the individual with I/DD has a relationship. This physician can explain what each of these treatments mean specific to prognosis with COVID-19 for the person’s disability and medical conditions.