LIGA Golf Cart Request Due to Disability Questionnaire

LIGA Golf Cart Request Due to Disability Questionnaire

 

The purpose of this questionnaire is to gather information from anyone seeking to use a golf cart because of a permanent disability in any Long Island Golf Association Championship or Qualifying Round where walking is required. Please use additional pages as necessary. (To print this questionnaire, highlight it all, right click in the highlight and choose "Copy." Then open a new document in your word-processing software, right click in the new document and choose "paste;" then print out the new document.)

1) Please explain the nature of your disability and why it requires that you use a golf cart.

 

 

 

 

2) A) Is your disability permanent or temporary?     B) How long have you suffered from this disability?  C) How does this disability limit your ability to walk during tournament golf?  D) Is it stable?   E) Has it become worse over time?

 

 

 

 

3) Please provide a medical report from your physician who has evaluated your condition, describing the nature and extent of your disability and explaining why it would be beyond your ability to walk during this event. Such report must explain, in detail, your diagnosis and symptoms and specifically describe how your condition impairs your ability to walk in general and during a golf tournament. Such report should be attached to and submitted together with this completed questionnaire.

4) Please provide the name, address and telephone number(s) of your treating physician(s) for the condition which you believe requires use of a golf cart.

 

 

 

 

5) What is the current treatment plan for your condition? Identify medication(s) and therapy utilized to treat your condition and any side effects experienced.

 

 

 

 

 

 

 

 

 

6) If your condition relates to a cardiac (heart) problem, please answer the following:

a) Have you ever had coronary artery bypass surgery or an angioplasty?

b) Do you take cardiac medications, and if so, what are the medications and current dosages?

 

 

 

 

c) Do you experience shortness of breath, chest or arm tightness, leg cramping while walking? If so, how many yards can you walk before stopping?

 

 

 

 

 

7) Have you ever been given an impairment rating for this condition relating to worker’s compensation, a personal injury claim, or for Social Security Disability purposes? If so, please provide details as to the rating, which body parts and basis for the rating (AMA Guides to Permanent Impairment, 5th edition, or to a local or state rating guide).

 

 

 

 

 

8) Can you walk up a flight of stairs without assistance, without walking aids, and without holding onto the handrail? How many yards can you walk on level ground without having to stop or without assistance?

 

9) Do you use walking aids (cane, crutches, walker, wheelchair, back brace, leg brace)? If so, describe the length of time you use them each day.

 

 

 

 

 

10) Please attach a list of the golf tournaments you have played in during the past five years and state whether you walked or used a golf cart during these tournaments.

 

11) On average, how many times a week do you play non-tournament golf?

12) In non-tournament play, what percentage of the time do you walk when you play? What percentage of time do you use a golf cart?

 

I certify that the information supplied above and in any attachments is true and correct.

 

 

Signature_________________________________________________________________________

 

Print Name________________________________________ Date___________________________

 

 

Please note that this Questionnaire, including all information requested above, as well as the medical report from the physician, must be submitted to the LIGA within three days of submission of the relevant championship entry application. All relevant materials must be submitted by the player themselves (not a caddie or other party) in writing and received by the LIGA, 114 Old Country Road, Suite LL80, Mineola, NY 11501 or by e-mail to LIGA@longislandgolf.org. Telephone submissions will not be accepted.