Federal Medical & Job Options Review

1
Full Legal Name (First and Last)* This field is required.
First Name
Last Name
2
Email Address* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Preferred Contact Method* This field is required.
Please Select
Please Select
Phone
Email
Text
5
What primary issue do you need the most help with right now? (Select one)* This field is required.
OPM Disability Retirement
OWCP
FMLA
Reasonable Accommodation
Medical restrictions
LWOP/Attendance
Unsure
6
Current Federal Agency* This field is required.
7
Current Position Title
8
Exact date of career appointment* This field is required.
Date
Month
Day
Year
9
Current Employment Status* This field is required.
Please Select
Please Select
Working Full Duty
Light/Modified Duty
Teleworking
On LWOP
On FMLA
On OWCP
Separated
Resigned
Retired
10
Which physical demands are regularly required in your position?
Prolonged sitting
Standing/walking for long periods
Heavy lifting/carrying
Bending/stooping/kneeling
Reaching above shoulders
Fine motor skills/keyboarding
Driving/operating machinery
Physical restraint/security work
Climbing
Other
11
Which cognitive demands are regularly required?
Sustained concentration/Focus
High-stakes decision-making
Emergency response/Crisis management
Conflict management/De-escalation
Public interaction/Customer service
Supervisory/management duties
Report writing/Complex data analysis
Multitasking/High-paced workflow
Working rotating shifts/Irregular hours
Other
12
Primary Medical Condition
13
Approximate Onset Date
14
Are your medical symptoms expected to continue for longer than one year?
Yes
No
15
Do you have a secondary medical condition contributing to your limitations?
Yes
No
16
How do your medical conditions limit your ability to perform your job duties?
Unable to maintain regular attendance
Unable to perform physical demands
Unable to maintain sustained focus/concentration
Unable to interact effectively with coworkers/public
Unable to complete full shifts due to pain/fatigue
Medication side effects impair safety/performance
Other
17
Have your conditions caused you to miss work, use leave excessively, or go on LWOP?
Yes
No
18
Have you requested or received any workplace accommodations or modified duties?
Yes
No
19
Are you currently facing any disciplinary action, proposed removal, or fitness-for-duty exam?
Yes
No
20
How did your workplace injury or illness occur?
Please Select
Please Select
Single traumatic event/accident
Repetitive physical strain over time
Exposure to toxic substances/hazards
Work-related psychological trauma/severe stress
Work duties worsened a pre-existing condition
Other
21
Approximate Date of Workplace Injury or Exposure.
Date
Month
Day
Year
22
Is your FMLA request for your own medical condition, or to care for a family member?
Please Select
Please Select
Own Condition
Family Member
23
Federal Retirement System
Please Select
Please Select
FERS
CSRS
Unsure
24
SSDI Application Status
Please Select
Please Select
Not Applied
Pending
Approved
Denied/Appealing
25
VA Disability Claim Status
Please Select
Please Select
No Claim
Pending
Approved
Denied/Appealing
26
Primary Treating Physician/Provider Name
27
Provider Specialty (e.g., Orthopedics, Psychiatry, Primary Care)
28
List any other relevant medical providers and their specialties (Optional)
29
Acknowledgments* This field is required.
I understand Konexo Consulting is not a law firm.
I authorize Konexo to review this information to evaluate my case.
I certify this information is accurate to the best of my knowledge.
30
Signature* This field is required.
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