Free 10692.FH11 - Indiana

PHYSICIAN'S STATEMENT OF DISABILITY
State Form 10692 (R4 / 5-99)

DEPARTMENT OF NATURAL RESOURCES Division of Fish and Wildlife 402 West Washington St., Room W273 Indianapolis, IN 46204

NOTE TO APPLICANT:

This form is to be returned to the Division of Fish and Wildlife by the applicant with the Special Permit for Persons with Disabilities Hunter application. A Statement of Disability is required only once if the disability is of a permanent nature. This form will be returned to the applicant if all applicable sections are not fully completed. The Indiana Department of Natural Resources may issue a special permit for the taking of wildlife by an individual who has a disability of such a nature that it is difficult or impossible for him to be in a position to take wildlife unless given special consideration. For the purpose of special disability hunting permits, a person is disabled if he or she has a physical impairment due to injury or disease, congenital or acquired. Generally, permits are issued to hunt from a vehicle for persons who cannot walk or have great difficulty in walking, and/or to hunt with a crossbow for persons who cannot use a regular bow. This form will be returned to the applicant if all applicable sections are not fully completed.
Telephone number

NOTE TO PHYSICIAN:

PLEASE TYPE OR PRINT
Name of doctor Address (number and street, city, county, state, ZIP code) Name of applicant Address (number and street, city, county, state, ZIP code) Date of birth (month, day, year)

This is to certify that _________________________________________________________________ has been under my professional care since ____________________________________________________ for the following (check one) Describe completely: permanent temporary disability

Please complete all applicable sections below. A. Cardiovascular conditions Describe walking limitations without pain or shortness of breath.

Describe upper body movement limitations without pain.

What restrictions does the applicant have performing normal daily activities?

If known, what is the American Heart Association's Heart Disease classification? (check one) 1 When was the applicant's surgery? (month, day, year) Post Chest Surgery 2 3 4 5 Are there any unusual circumstances causing pain? (please explain)

Page 1 of 3 pages

B. Pulmonary conditions Provide the results of any pulmonary function studies.

Provide specific details of limitations of activity, especially walking, without shortness of breath.

What restrictions does the applicant have performing normal daily activities?

Describe any upper body limitations of activity or strength.

C. Neurological conditions Describe walking limitations (especially in terms of terrain and/or distance).

Is an assistive device needed to help the applicant walk? (please describe)

Does the applicant use a wheelchair for ambulation? Yes Describe any upper body limitations of activity or strength. No Part time Full time

D. Arthritic conditions What type of arthritis? What joints are affected?

If the upper body is affected, what is the range of motion, in degrees, of the joint(s)?

Describe upper body movement limitations without pain.

If lower body is affected, how well can the applicant walk (especially in terms of terrain and distance)?

What restrictions does the applicant have performing normal daily activities?

Page 2 of 3 pages

E. Amputations/Orthopedic conditions 1. Amputations Indicate the nature and extent of the amputation(s).

What, if any, prosthetic devices does the applicant have?

If a lower limb amputation is involved, how does it affect the applicant's walking ability (especially in terms of terrain and distance)?

Does the applicant use a wheelchair? Yes No Part time Full time 2. Orthopedic conditions Describe any walking limitations (especially in terms of terrain and distance).

Describe any upper body strength and/or movement limitations.

F. Other If the extent of applicant's physical limitations (upper body strength/movement, walking ability) cannot be described above, please explain here.

If the applicant is not applying to hunt with a crossbow or from a vehicle, please provide a medical justification for applicant's requested method of hunting.

Signature of physician Page 3 of 3 pages

Date signed