Employee Details

Employee's Full Name

Employee's eNumber

Employee's Job Position

School where employee works   -- 21st Century Public Academy Charter 5-8 7 Bar ES A. Montoya ES ABQ Charter Academy Charter HS ACE Leadership Charter HS Adobe Acres ES Alameda ES Alamosa ES Albuquerque HS Albuquerque Talent Development Academy Charter HS Alice King Community Charter K-8 Alvarado ES Apache ES Armijo ES Arroyo Del Oso ES Atrisco ES Atrisco Heritage Academy HS Bandelier ES Barcelona ES Bel-Air ES Bellehaven ES Career Enrichment Center & Early College Academy HS Carlos Rey ES Chamiza ES Chaparral ES Chelwood ES Christine Duncan Heritage Academy Charter PreK-8 Cibola HS Cien Aguas International Charter K-8 Cleveland MS Cochiti ES College and Career HS Collet Park ES Comanche ES Coral Community Charter HS Coronado ES Corrales ES Corrales International School Charter K-12 Cottonwood Classical Charter 6-12 Coyote Willow K-8 Del Norte HS Dennis Chavez ES Desert Ridge MS Desert Willow K-8 Digital Arts and Technology Academy Charter HS Dolores Gonzales ES Double Eagle ES Duranes ES E. G. Ross ES East Mountain Charter HS East San Jose ES eCADEMY HS Edward Gonzales ES Eisenhower MS El Camino Real Academy Charter K-12 Eldorado HS Emerson ES Ernie Pyle MS Eugene Field ES Freedom HS Garfield MS George I. Sanchez K-8 Georgia O'Keeffe ES Gilbert L. Sena Charter HS Gordon Bernell Charter HS Governor Bent ES Grant MS Griegos ES H. Humphrey ES Harrison MS Hawthorne ES Hayes MS Health Leadership Charter HS Helen Cordero ES Highland HS Hodgin ES Hoover MS Inez ES International School at Mesa del Sol Charter PreK-12 Jackson MS James Monroe MS Janet Kahn ES Jefferson MS Jimmy Carter MS John Adams MS John Baker ES Juvenile Detention Center 6-12 Kennedy MS Kirtland ES Kit Carson ES L.B. Johnson MS La Academia de Esperanza Charter 6-12 La Cueva HS La Luz ES La Mesa ES Lavaland ES Lew Wallace ES Longfellow ES Los Padillas ES Los Puentes Charter 7-12 Los Ranchos ES Lowell ES M. A. Binford ES MacArthur ES Madison MS Manzano HS Manzano Mesa ES Marie M. Hughes ES Mark Armijo Academy Charter HS Mark Twain ES Matheson Park ES McCollum ES McKinley MS Mission Avenue ES Mitchell ES Monte Vista ES Montessori of the Rio Grande Charter PreK-6 Montezuma ES Mountain Mahogany Charter K-8 Mountain View ES Native American Community Academy Charter K-12 Navajo ES New America School Charter HS New Futures HS New Mexico International Charter K-4 Nex+Gen Academy HS North Star ES Onate ES Osuna ES Painted Sky ES Pajarito ES Petroglyph ES Polk MS Public Academy for Performing Arts Charter 6-12 Reginald Chavez ES Rio Grande HS Robert F Kennedy Charter 6-12 Roosevelt MS Rudolfo Anaya ES S. R. Marmon ES S. Y. Jackson ES San Antonito ES Sandia Base ES Sandia HS School on Wheels HS Siembra Leadership Charter HS Sierra Vista ES Sombra Del Monte ES South Valley Academy Charter 6-12 Sunset View ES Taft MS Taylor MS Technology Leadership Charter HS Tierra Antigua ES Tomasita ES Tony Hillerman MS Transition Services HS Tres Volcanes K-8 Truman MS Valle Vista ES Valley HS Van Buren MS Ventana Ranch ES Vision Quest MS Volcano Vista HS Washington MS West Mesa HS Wherry ES Whittier ES William W. & Josephine Dorn Community Charter K-5 Wilson MS Zia ES Zuni ES

Contact E-Mail Address  

Contact Phone Number  

Address

Major Bodily Functions Affected

Mobility

Bending

Lifting

Reaching

Sitting

Standing

Walking

Self-Care

Caring for self

Eating

Sleeping

Activity Limitations

Breathing

Hearing

Seeing

Speaking

Cognitive

Concentrating

Learning

Reading

Thinking

Participation Restrictions

Interacting with others

Performing manual tasks

Working

Bodily Functions

Digestive

Endocrine

Genitourinary

Hemic

Immune

Lymphatic

Musculoskeletal

Neurological

Normal cell growth

Operation of an organ

Reproductive

Respiratory

Special sense organs and skin

Please describe other functions affected:

Service Animals

Describe Service Animal Needs