Health

Self-Declaration by a Person with a Disability

Factual self-declaration of long-term impairments, barriers, participation, and accommodations, with optional consent-based ICD data.

Updated on 2026-07-29

What this document is for

Report one's own experience and needed accommodations without producing a diagnosis, medical report, or automatic eligibility decision.

Information to prepare

The fields below come from the template itself and help you check the information before filling it in.

Document details

Purpose relatorio
Authorized issuer name
Profissão professional
Professional registration and state
Name full
CPF

Additional information

CID laudo
Autorizacao CID

Place, date and signatures

Signing city
Receipt date

How to complete and review it

Confirm the document's purpose and the requirements of the person or organization that will receive it.
Gather the supporting records and copy names, numbers, dates, and amounts exactly as they appear in the real sources.
Complete the applicable fields, review the full preview, and correct inconsistencies before exporting.
Review signatures, attachments, witnesses, deadlines, and formalities required for the specific case.

Limits and precautions

The template organizes the information provided, but it does not prove identity, authenticity, or the truth of the facts.
It does not replace an official record, professional advice, or legal, accounting, medical, or administrative review.
Acceptance, signatures, witnesses, notarization, registration, and attachments depend on the purpose, recipient, and current rules.

Legal reference stated in the template

The Brazilian reference recorded in the catalog is reproduced below in Portuguese. It is not a legal conclusion and does not replace checking the current rule. Use this statement as a starting point and check the current wording and the requirements of the specific case.

Lei nº 13.146/2015 e Lei nº 13.709/2018 (LGPD)

Where to check official information

The portals below provide broad access to public services and rules. They do not, by themselves, confirm that this template fits your case.

Questions about this template

What is Self-Declaration by a Person with a Disability used for?

Report one's own experience and needed accommodations without producing a diagnosis, medical report, or automatic eligibility decision.

What information should I prepare before filling it in?

Start with Purpose relatorio, Authorized issuer name, Profissão professional, Professional registration and state, Name full, CPF. Check each item against real records before completing the document.

Does this template replace professional advice or an official record?

It does not replace an official record, professional advice, or legal, accounting, medical, or administrative review.

Do I need notarization, registration, or witnesses?

Acceptance, signatures, witnesses, notarization, registration, and attachments depend on the purpose, recipient, and current rules.