Disability Review Forms
Child Disability Packet:
To be completed by the parent/guardian or authorized representative:
- Disability Questionnaire: DOH-5139 (English) (PDF)
- Description of Child Activities: DOH-5153: (English) (PDF)
- Authorization for the Release of Information Pursuant to HIPAA - DOH-5173 (English) (PDF)
To be completed by the child's doctor:
- Childhood Medical Disability Report - DOH-5151 (PDF)
To be completed by the child's teacher or administrator:
- Questionnaire of School Performance - DOH-5152. (PDF)
For questions regarding disability documentation requirements email SDRU@health.ny.gov or call the State Disability Review Unit toll free number 1-866-330-0591 Monday through Friday 8am-5pm.
