Language
English (US)
Español
Disability Retirement Intake
Please complete the certification and signature section to proceed.
Purpose of this intake: This form helps Konexo gather key information about your situation so a consultant can review your case before your consultation. Please provide accurate facts and dates to the best of your ability. You may upload supporting documents such as medical records, agency letters, forms, employer notices, and correspondence. Submitting this intake does not create an attorney-client relationship and does not constitute legal advice. A Konexo consultant will review your information and follow up with you about next steps.
Name
*
First Name
Last Name
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred contact method
*
Phone
Email
Mail
Other
Section 2 – Federal Employment Information
Agency
*
Duty station
*
Position title
*
Retirement system
*
FERS
CSRS
Years of federal service
*
Last day worked
*
-
Month
-
Day
Year
Date
Section 3 – Medical Condition
Primary medical condition
*
Secondary conditions
Date symptoms began
-
Month
-
Day
Year
Date
Date diagnosed
-
Month
-
Day
Year
Date
Treating physician
First Name
Last Name
Describe how your medical condition has progressed
Section 4 – Functional Limitations
Functional Limitations
Standing
Walking
Sitting
Lifting
Bending
Using hands
Concentration
Memory
Attendance
Working full schedule
Explain how your condition prevents you from performing the essential duties of your position
Section 5 – Accommodation History
Did you request reasonable accommodation?
Yes
No
Date requested
-
Month
-
Day
Year
Date
Result
Approved
Denied
Ignored
Were you offered light duty or modified duty?
Yes
No
Section 6 – Work Status
Current employment status
Employed
Unemployed
On leave
Retired
Other
Have you used sick leave because of the condition?
Yes
No
Have you been on LWOP because of the condition?
Yes
No
Describe how your attendance has been affected
Section 7 – Timeline
Provide a timeline of important events such as diagnosis, treatment, accommodation requests, leave usage, and last day worked
Section 8 – Document Upload
Medical records
Doctor reports
Medical records
Imaging or test results
Work restrictions
Agency letters
Accommodation requests or denials
Leave records
Agency correspondence
Disciplinary or performance documents if related
Other supporting documents
SSDI paperwork
OWCP documents
Any additional supporting evidence
Section 9 – Certification
*
First Name
Last Name
Medical Conditions
Please provide detailed information about your medical condition and treatment history.
Accommodation History
Timeline
Document Upload
Digital signature
*
Work Status and Leave History
Please provide accurate information about your work status and leave history related to your medical condition.
Medical Evidence
Employment Records
Other Supporting Documents
Timeline Entries
Please add timeline events related to your condition. Examples include Diagnosis, Medical treatment, Accommodation request, Accommodation denial, Leave usage, Last day worked, Light duty assignment, Supervisor response.
Timeline
Please provide timeline entries related to your medical condition and accommodations.
Event date
-
Month
-
Day
Year
Date
Document Upload
Please upload supporting documents organized by category for clarity and ease of review.
Date signed
*
-
Month
-
Day
Year
Date
Preferred Method of Contact
Phone
Email
Mail
Other
Other
Do you agree to the privacy policy?
*
I agree
Additional Comments or Information
Submit
Submit
Should be Empty: