Nevada Department of Employment, Training and Rehabilitation
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Nevada Department of Employment, Training and Rehabilitation Application for Vocational Rehabilitation Service
Case# L A S T N A M E F I R S T N A M E P R E V I S OC IAL S EC U MO U S RIT Y # N A M E S
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C U R R E N T S T R E E T A D D R E S S Apt # C I T Y S T A T E Z I P C O D E
M A I L I N G A D D R E S S ( C I T Y S T A T E Z I P C O I f D i f f e r e n t F r o m D E C u r r e n t A d d r e s s ) C O U N T Y T E L C E D A T E M A I L A D D R E S E P H O N E # L L E O F S # B I R T H ( ( ) ) GENDER 1 of 12 P-VR Appl / Rev 9 - 07/2014 M A L E CONTACT PERSON’S NAME AND TELEPHONE NUMBER (SOMEONE F E M A L E WHO’S PHONE NUMBER IS DIFFERENT THAN YOURS WHO WOULD BE ABLE TO GIVE YOU A MESSAGE) U.S. Name: MILITAR Y Relationship: VETERA N? Number: ( ) Contact Person NOT Living in your home YES NO Name: Relationship: Number: ( )
Address:
U.S. CITIZEN? RACE (CHECK ONE OR MORE) YES NO WHITE BLACK OR AFRICAN AMERICAN If No: Do you have an ASIAN Alien AMERICAN INDIAN / ALASKA NATIVE Registration Card? NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER YES NO
ETHNICITY: EMPLOYMENT AUTHORIZATION HISPANIC/LATINO YES DOCUMENT? NO YES NO OTHER (SPECIFY)
2 of 12 P-VR Appl / Rev 9 - 07/2014 Who referred you? Check / Circle one: Social Security Administration or Disability Determination Services Doctor, Hospital, Mental Health Law enforcement, Corrections, Court Job Connect, Workers’ Comp. Rehabilitation program in your community Welfare or public assistance agency University, College, or Vocational school Grade school or high school Self-referral, Friend, Family Please check one of the following which best describes your current living arrangement: Private residence (On your own, with family or roommate) Group home Rehabilitation facility Mental health facility Nursing home Jail/Adult correctional facility Halfway house Homeless/shelter Would you like to register to vote today MARITAL STATUS Yes No Form# SINGLE MARRIED SEPARATED Please select one: DIVORCED WIDOWED Currently registered Not EligibleNot Interested House hold Information: Number in Family Number of Dependents Parents monthly income if under age 18 Ho u s e h o ld me m b e rs : Name: Age:_ Relationship: Occupation: Name: Age:_ Relationship: Occupation: Name: Age:_ Relationship: Occupation:
What is your primary (largest) source of support? Monthly Amount $ Check one of the following: Your personal income (earnings, interest, dividends, rent) Your spouse’s income, or support from family and friends Public support such as SSDI, SSI, TANF, etc. Other sources such as insurance or charities RECEIVED BY:
Agency Representative : IDENTIFICATION One (1) Item from List A Provide verification for the following OR identification: One (1) Item from List B A N D One (1) Item from List C L i st A L i st B State issued Driver’s License or State I.D. Card w/Picture or Information (Name, United States Passport Sex, Date of Birth, Height, Weight & Certificate of United States Citizenship Color of Eyes) Certificate of Naturalization U.S. Military I.D. Card A N D Unexpired Foreign Passport w/Attached L i st C Employment Authorization Original Social Security to be Witnessed Alien Registration Card w/Photograph at Intake Birth Certificate Issued by State, County or Municipal Authority Unexpired INS Employment Authorization What is your highest level of education? Check one: No formal schooling Some elementary school (grades 1-8) Some high school (grades 9-12) but no high school diploma Special education certificate of completion/attendance High school diploma GED (high school equivalency certificate) Name of High School Some college/vo-tech – No degree Present Grade
AssocVocatiioanate l/DTegechreenical Certificate Bachelor’s Degree Master’s Degree or Higher College/Vo-Tech Schools : Name of School: Address of School :
How can the Bureau be of assistance to you? What employment related services are you seeking: Are you working? If yes, where: If no, check one:
OH.S.the Stur den t O th e r S t uden t T raNineeot E/mInptern/Voloyed lunteer If you are employed, how many hours do you usually work per week? If you are employed, what are your current WEEKLY earnings? $ (gross wages, salaries, tips or commissions before payroll or tax deductions) Are you currently receiving any of the following?If yes, please list the MONTHLY amount. SSDI (Social Security Disability Insurance) Amount: $_
SSIGene (Sralupp Alsesistamenntalce Sec (Puburitylic Assista Incomen)ce) Amount: $_ Veterans’ disability benefits Amount: $ TANF (Temporary Assistance for Needy Families) Amount: $ Any other public support Amount: $ Workers’ compensation Amount: $ (Please describe)_
Do you have any of the To help us coordinate your services, following types please of medical insurance check any other services you are coverage? Check one or more: receiving. Check one or more if you are receiving the following: Medicareid Workers’ Compensation GTeenempralorary Assista Assinstacen (ceGA) (TAN$F ) $ Private insurance through Food Stamps $ employment Children and Family Services Insurance Company Foster Care No Medical Insurance Coverage Child Support Enforcement Other Public Insurance Private Child Care insurance through other means: Adult Protective Services (for example, insurance through Low Income Energy Assistance your parents or spouse) Medicaid Working Healthy Other None COMMUNICATION While in school, did you ever ACCOMMODATIONS have an Individualized Regular print Education Program or IEP OBrathiellre language (specify) (special education)? Large print YES NO What is your primary means of Have you ever been convicted of a transportation? felony? Personal Vehicle Yes No Public Transportation Details: Other Probation Officer: Phone # ( )
W O R K H I S T O R Y Check here if no work history If currently working how many hours per week do you work? Hourly Wage: Li s t c urre n t or l a s t j ob f ir s t . I f y ou run out of space you may continue on the back side of this sheet. Name of Employer: Address: Job Duties: Title of Position Held: Dates of Employment: From: To: Mo/Yr Mo/Yr Reason for leaving:
Name of Employer: Address: Job Duties: Title of Position Held: Dates of Employment: From: To: Mo/Yr Mo/Yr Reason for leaving:
Name of Employer: Address: Job Duties: Title of Position Held: Dates of Employment: From: To: Mo/Yr Mo/Yr Reason for leaving:
Name of Employer: Address: Job Duties:
Title of Position Held: Dates of Employment: From: To: Mo/Yr Mo/Yr Reason for leaving: DISABILITY (Check all that apply) What is the primary medical condition, injury, physical/mental impairment or disability that limits your ability to work?
When did these impairments/disabilities begin?
Month / Year AIDS/HIV Deaf - Blind Alcohol or Other Drug Disorder Deaf or Hard of Hearing Post Paraplegia or Quadriplegic Amputation Depression Post-Traumatic Stress Disorder Arthritis Diabetes Respiratory/Pulmonary/Allergies Attention Deficit Disorder Epilepsy Severe Arthritis Autism Fibromyalgia Specific Learning Disability Back Injury Heart Disease Spinal Cord Injury Blindness or Visual Impairment Hemophilia Stroke Brain Injury Hip/Knee, Other Joint Cancer Dysfunction Carpal Tunnel Kidney Failure _(Repetitive Use Syndrome) Mental Illness Cerebral Palsy (CP) Muscular Dystrophy Cognitive Disability Multiple Sclerosis Cystic Fibrosis Myofascial Disorder Unknown
Other CURRENT PHYSICIAN / MEDICAL PROFESSIONAL 1. Name Type of Physician Address Phone/Fax Number 2. Name Type of Physician Address Phone/Fax Number 3. Name Type of Physician Address Phone/Fax Number If additional space is needed please enter information on the back of this page. HOSPITALIZATIONS Name of Hospital: Address: Reason: Name of Hospital: Address: Reason: LIST OF MEDICATIONS CONFIDENTIAL PERSONAL INFORMATION The Bureau of Vocational Rehabilitation is a state and federally funded agency that assists persons with disabilities in achieving or maintaining employment. I understand that it is necessary for the Bureau to collect personal information in connection with my rehabilitation program. I understand that such information will be collected, to the maximum extent practicable, from me. T he Bureau may only use personal information for purposes directly connected with the provision of services and the administration of the program under which services are provided. I understand that information is available to me when requested in writing, except where the Bureau believes such information can reasonably be expected to cause physical or emotional harm. In this instance, the Bureau shall release such information through a qualified medical or psychological professional or to an authorized representative. Any information provided by me is subject to verification and review through the Social Security Administration. I understand that my eligibility and/or provision of services may be impacted if I refuse to provide personal information that is requested by the Bureau. I understand that my personal information will be held confidential by the Bureau and will not be disclosed to any other person or entity except as noted in the Information and Disclosure Form. Section 504(A) of the Workforce Investment Act of 1998; Section 12c of the Rehabilitation Act of 1973 as Amended; 29USC711c and 721(a)(6)(A); 34CFR361.38; NRS 426.573, 426.610, 432B.220, 615.280, 615.290; 629.061
In making this application for vocational rehabilitation services, I acknowledge that:
o Purpose of applying for services: I am applying for vocational rehabilitation services for the specific purpose of getting and/or keeping a job.
o Choice to proceed with services: I understand I have the freedom to choose whether or not to enter into or remain in a rehabilitation counseling relationship and whether or not to participate in any rehabilitation assessment or service. My counselor will review with me potential consequences of choosing not to participate in any particular service. I may request case closure at any time. o Change of information: It is my responsibility to inform my counselor of any changes related to this application, such as changes in my address, income or employment.
o Prior written approval: BVR/BSBVI will only pay for goods and services that have been pre-authorized by my counselor, as described in the agency's Information and Disclosure Sheet. Inclusion of a good or service on the IPE is not considered pre-authorization. I understand that I may have to pay for goods and services for which my counselor has not provided pre-authorization.
o Previous Debt: I understand the agency will not pay any outstanding debt, including student loans I have incurred prior to this case being opened or any debt incurred during this case.
o Financial Participation: I understand that I will be asked to furnish financial information and my financial needs will be considered in determining my participation in the cost of those vocational rehabilitation services which require the expenditure of case service dollars. Some services are exempt from the financial participant requirement.
o Comparable Benefits: I understand that when applicable, I will be asked to apply for and secure comparable benefits that are available to help pay for the cost of my services. Comparable benefits may include but are not limited to health insurance, Pell Grant, Community Agencies such as Public Mental Health Agencies, etc. Some services are exempt from the comparable services requirement.
o Confidentiality: I have read and understand the agency's policies in regards to confidentiality of personal information as described on the Information and Disclosure Sheet. I understand the limits to confidentiality and when information may be disclosed without my written consent. o Risks of electronic communication: I understand the risks of electronic communication, including e-mail communication between the agency and me, and that confidentiality cannot be assured if I elect to communicate electronically.
o Sharing Information with DETR and SSA: I expressly give my permission for information about me to be shared within the Department (DETR). Rehabilitation Services will also have access to Information in my Social Security, Disability Determination, SRS, and employment records.
o Amending Inaccurate Information in my file: If I believe information in my record of services is inaccurate or misleading, I may request that the Bureau of Vocational Rehabilitation amend or remove the information. If the information is not amended or removed the request for an amendment must be documented in the record of services.
o Liability of State for third party actions: The state of Nevada, Nevada Department of Employment, Training & Rehabilitation, the Rehabilitation Division and the Bureau of Vocational Rehabilitation and their officers, agents, employees and elected and appointed officials are not responsible in any manner for damages caused to a client by third parties, including, but not limited to vendors on an approved list maintained by the State of Nevada, Nevada Department of Employment, Training & Rehabilitation, the Rehabilitation Division and the Bureau of Vocational Rehabilitation and hereby specifically disclaim any liability therefore. In addition, the State of Nevada will not waive and intends to assert available NRS chapter 41 liability in all cases.
o Auxiliary Aids and Services: I understand Auxiliary aids and services are available if required to receive equal access to services due to my disability. I will inform my VR counselor if auxiliary aids or services are needed. o Discrimination: No one will be discriminated against by Rehabilitation Services because of disability, race, religion, sex, color, national origin, length of residency in the state, or ancestry. o Violence, threats, harassment, intimidation and other acts of aggression and disruptive behavior will not be tolerated and may result in case closure and, when warranted, filing of criminal charges. Acts of aggression can include oral or written statements, gestures, or expressions that communicate a direct or indirect threat of physical or mental harm or, indirect acts such as damage to personal property. ACKNOWLEDGEMENT OF ACCEPTANCE
Please place your initials beside each title of the document you have received.
____ I have been provided the agency’s Information and Disclosure Sheet and informed about the protection, use and release of personal information and the conditions under which my personal information may be released without my written consent.
____ I have been informed regarding the risks of electronic communication. I agree to the exchange of information regarding myself through the following methods (initial all that apply):
_____ok to email_____do not communicate with me through e-mail
_____telephone - OK to leave detailed message
_____telephone - leave only message to return call _____telephone - do not leave a message
_____OK to use facsimile to transmit information
_____Only hand deliver or mail information regarding me
_____Other______I have been informed of my opportunity for review of decisions made by my Rehabilitation Counselor regarding my application, eligibility and the furnishing or denial of service if I do not agree with the decision.
____ I have been informed of the Client Assistance Program and have been provided a copy of the steps I need to take concerning communication and formal appeal.
____ I have been informed of and have been provided a copy of The Participant Bill of Rights.
____ I have been informed of the professional qualifications of VR Counselors and Rehabilitation Specialists. I agree to enter into a rehabilitation counseling relationship at this time.
ApplicantSignature______Date______
Parent/Guardian/Legal Rep Signature______Date______
Signature of Individual who filled out application if different from above
______
Parent/Guardian/or Representative's Address
______Telephone Number______
Email address______