Utah Form 1GA, “Evidence of Impairment,” is the medical verification document the Utah Department of Workforce Services uses to confirm that a General Assistance applicant has an impairment preventing basic work activities in any occupation.1Utah Department of Workforce Services. General Assistance – How the Program Works To use it, you take the blank form to a qualified medical provider, have them document your condition, and return the completed form to your Workforce Services caseworker or local employment center.
Why Workforce Services Asks for This Form
General Assistance is a state-funded program administered by the Department of Workforce Services for people who cannot work because of a verified medical impairment. It is separate from federal disability programs and has its own eligibility rules and benefit levels. Form 1GA is how the department confirms that your impairment is real, medically documented, and severe enough to prevent work in any occupation.1Utah Department of Workforce Services. General Assistance – How the Program Works Without a completed 1GA, the department cannot evaluate your medical eligibility.
Getting a Blank Form
Your caseworker will usually hand you Form 1GA during the General Assistance application process. If you need a copy sooner, contact your nearest Workforce Services employment center and ask for the Evidence of Impairment form. Office locations are listed at jobs.utah.gov. Have the blank form in hand before your medical appointment so the provider can complete their part during the visit.
Filling Out Your Portion
Enter your full legal name, date of birth, and contact information. Your name should match what Workforce Services has on file for your case, and if you have a case number, include it. Mismatched or missing identifiers slow processing, so check the details before you hand the form to your doctor.
What the Medical Provider Documents
The provider’s section captures the nature and severity of your impairment. The form asks for the specific diagnosis, an explanation of how it limits your ability to perform work-related tasks, and an assessment of whether the condition is temporary or ongoing. The provider signs to certify the findings.1Utah Department of Workforce Services. General Assistance – How the Program Works
Concrete functional limitations matter more than the diagnosis alone. Whether you can stand, sit, lift, concentrate, or follow instructions well enough to hold any job is what the reviewer weighs.
Who Can Sign
The medical section should be completed by a licensed physician (MD or DO), nurse practitioner, or physician assistant who has directly examined you and knows your medical history. For a mental health impairment, a licensed psychologist or psychiatrist is the appropriate signer. The provider needs firsthand knowledge of your condition, not just a chart review.
Turning the Form In
Once the provider finishes their portion, return the completed Form 1GA to your Workforce Services caseworker. You can drop it off in person at your local employment center, or ask your caseworker about fax or mail submission. Keep a copy for yourself before you hand it over.
If you were given a deadline, treat it as firm. Missing it can stall or derail your application and force you to restart parts of the process.
What Happens After Submission
Workforce Services reviews the medical evidence on the form along with the rest of your application and decides whether the documented impairment meets the program’s threshold for preventing work. A thorough, specific form can move quickly; a sparse one may prompt the department to request additional records or a follow-up evaluation.
Approved benefits are generally temporary and tied to the duration of your documented impairment. If the provider described the condition as temporary or improving, expect Workforce Services to request an updated Form 1GA later to confirm the impairment continues.
Not the Same as the Driver License Medical Form
Form 1GA is sometimes confused with the Utah Driver License Division’s Functional Ability Evaluation Medical Report, which evaluates whether a driver can safely operate a vehicle. The two forms serve different purposes and go to different agencies. If your medical evaluation is for your driver license, you need the DLD’s medical report form, available through the Driver License Division at dld.utah.gov or its Health Care Professionals portal, and it goes to the DLD rather than to Workforce Services.2Utah Driver License Division. Health Care Professionals