Nebraska AgrAbility ICS 09/04/03
AUTHORIZATION AND DIRECTION FOR DISCLOSURE
TO THE NEBRASKA AGRABILITY PROJECT
A Program Provided by the Easter Seals Society of Nebraska, Inc.
TO:
All Hospitals, Physicians, Counselors who have provided services to:
Client’s name:
I have accepted the services of the Nebraska AgrAbility Project, a program provided by the
Easter Seals Society of Nebraska, Inc., for the purpose of monitoring my health status and/or
rehabilitation services. I have authorized any representative of this organization to review all
records and information relating to my testing and treatment. I request your full cooperation with
the Nebraska AgrAbility Project and the Easter Seals Society of Nebraska, Inc.
You are hereby directed to furnish to the Nebraska AgrAbility Project any and all records
regarding my condition and treatment. Representatives of this organization may review and copy
all such records and information. I agree that a photostat of this authorization be accepted.
Dated this ______________ day of _______________, 20______
Signature:
Date:
Witness:
Date:
Nebraska AgrAbility ICS 09/04/03
Nebraska AgrAbility
ICS Client Information
Client Number __________
Date ______________
Responsible _______________________________
Client Name: _______________________________________________________
Address: _________________________________________________
County: ___________
City: ______________________________ State: _________
Zip: ____________________
Phone: _____________________________
SS#: _________________________
E-mail: ______________________________________________________
Directions to farm: ________________________________________________________
________________________________________________________________________
Name/Address of Guardian/Spouse if different from above:
_______________________________________________________________
Address: ______________________________________________
County: __________
City: ___________________________
State: ______
Zip: _________________
Phone: __________________________
E-mail: ________________________________
Contact Person Information (if client did not self-refer)
Contact Name: _________________________________________________
Organization: _________________________________________________
Address: ______________________________________________________
City: ________________________________ State: _________ Zip: ________________
Phone: ______________________________
E-mail: __________________________
Client Status: ______ New ______ On-going
Age: ______
Gender:
______ Re-opened
______ Deceased
DOB (dd/mm/yyyy): ______
______ Male
______ Female
Who is the client? (CHECK ONE)
______ Owner/Operator
______ Spouse/partner
______ No longer actively farming/ranching
______ Employee
Nebraska AgrAbility ICS 09/04/03
______ Dependent adult
______ Child (<18 years)
Type of Ag Operation (check ALL that apply):
______ Agri-business
______ Field/grain crops
______ Nursery crops
______ Orchard
______ Vegetable crops
______ Hay
______ Migrant
______ Seasonal worker
______ Dairy
______ Livestock
______ Poultry
______ Other animals
______ Specialized crops (mushrooms, flowers)
______ Other
Origin and Date of Disability (check the cause of the PRIMARY disability – CHECK ONE)
Agriculture-related
Year
Nonagricultural-related
Year
____ Vehicular incident
____ Chemical/pesticides
____ Tractor/farm machinery
____ Livestock/animals
____ Other ______________
____
____
____
____
____
____ Vehicular incident
____ Recreational
____ Falls
____ Other disabling condition
____
____
____
____
Work status at the time of referral (current work role on the farm – CHECK ONE):
_____ None
_____ Full time
_____ Part time (regular basis)
_____ Occasional (irregular basis, several times a year)
Nebraska AgrAbility ICS 09/04/03
Nebraska AgrAbility ICS 09/04/03
Type of disability at time of referral (Check ALL that apply):
Category
Injury/Amputation
Specific Disability Type
Amputation (Upper Extremity)
___ Above elbow
___ Below elbow
___ Hand
___ Finger
___ Thumb
Amputation (Lower Extremity)
___ Leg – Above knee
___ Leg – Below knee
___ Foot
___ Toe
___ Replant (specify) _________
Neuromuscular
Diseases
___ Amyotrophic lateral sclerosis
___ Friedreich’s ataxia
___ Guillain-Barre syndrome
___ Huntington’s disease
___ Muscular dystrophy
___ Myasthenia gravis
Neurological
Condition/Disorder
___ Cerebral vascular accident (stroke)
___ Cerebral palsy
___ Epilepsy
___ Multiple sclerosis
___ Peripheral neuropathies
___ Other____________
Other Disease
___ Blood related disease (hemophilia, sickle cell anemia, leukemia)
___ Cancer
___ Cardiovascular disease
___ Chronic obstructive pulmonary disease (Respiratory impairment)
___ Chronic fatigue syndrome
___ Fibromyalgia
___ Kidney disease
___ Arthritis /Rheumatic diseases
___ Other____________
Sensory
Impairments
___ Deafblind
___ Hearing impairment
___ Visual impairment
___Other____________
Other
___ Chemical dependency
___ Chemical sensitivity
___ Diabetes/metabolic disorder
___ Mental illness
___ Mental retardation
___ Other____________
___ Back injury
___ Joint injury (shoulder, elbow,
wrist, hip)
___ Orthopedic injury (other)
___ Spinal cord injury- paraplegic
___ Spinal cord injury - quadriplegic
___ Traumatic brain injury
___ Other ____________
___ Parkinson’s disease
___ Poliomyelitis
___ Spinal muscular atrophy
___ Spinocerebellar degeneration
___ Other____________
Nebraska AgrAbility ICS 09/04/03
Independent Living needs at time of referral (Check ONE for each ability):
Assistance needs
None
Some
Total
Eating/feeding
Physical mobility
Communication
Dressing/grooming
Bathing/toileting
Driving
Independent Work needs at time of referral (check ONE for each ability)
Assistance needs
Operate tractors/farm machinery
Operate hand/power tools
Work with livestock
Perform other essential farm/work tasks
Manage farm/ranch/business finances
Maintain farmstead and equipment
None
Some
Total
Nebraska AgrAbility ICS 09/04/03
Access farm/ranch buildings
EASTER SEALS NEBRASKA
PEER SUPPORT NETWORK
ACCEPTANCE AND PARTICIPATION AGREEMENT
Authorization and direction for disclosure by the Easter Seals Nebraska.
I,
, agree to participate in the Easter Seals
Nebraska (ESN) Peer Support Network for the purpose of receiving assistance from a
farm family experiencing similar limitations as my own. I also may be asked to serve as a
peer support person for ESN for the purpose of providing assistance to farm families
experiencing similar limitations to my own.
I further authorize ESN to disclose my name, address, telephone number, and disability
for the purpose of participation in the Peer Support Network.
Dated this __________ day of _______________, 20____
Signature:
Date:
Witness:
Date:
Nebraska AgrAbility ICS 09/04/03
THE NEBRASKA AGRABILITY PROJECT
PHOTO RELEASE
Client’s name:
The undersigned, in partial recognition of services rendered and benefits conferred by the
Easter Seals Society of Nebraska, Inc., hereby authorizes the Easter Seals Society of
Nebraska, Inc., its employees, agents, and assigns, to release any pictures, or photographs
taken of the above-named client for publication for purposes of conveying information
concerning the named individual and/or the Easter Seals Society of Nebraska, Inc. The
undersigned hereby agrees also to hold the Easter Seals Society of Nebraska, Inc.
harmless of liability should such pictures or photographs, either accompanied or
unaccompanied by printed material, appear in other publications by whomsoever
published, circulated, or distributed.
Signature:
Date:
Witness:
Date:
Nebraska AgrAbility ICS 09/04/03
WAIVER OF LIABILITY
Client’s Names:
The undersigned, individually or as parent or natural guardian, in partial recognition of
services rendered and benefits conferred by the Easter Seals Society of Nebraska, Inc.
hereby releases and forever discharges the Easter Seals Society of Nebraska, Inc., its
agents and assigns, from any and all claims, demands, or actions, causes of action or suits
of whatsoever kind or nature for damages sustained by the above-named clients or
accruing to the undersigned in consequence of any accident or occurrence resulting from
the use of durable medical equipment and/or participation in any activity or program of
the Easter Seals Society of Nebraska, Inc. and when the above-named client is not on the
premises of said Easter Seals of Nebraska, Inc. and is engaged in any venture or activity
solely on his or her own behalf.
Signature:
Date:
(Signature of client of legal age, parent, or guardian if minor)
Witness:
Date:
Nebraska AgrAbility ICS 09/04/03