Nevada Department of Employment, Training and Rehabilitation
Application for Vocational Rehabilitation Service
Case# ______LAST NAME / FIRST NAME / MIDDLE INITIAL / PREVIOUS NAMES USED / SOCIAL SECURITY #
X X X - X X - ______
CURRENT STREET ADDRESS / Apt # / CITY / STATE / ZIP CODE
MAILING ADDRESS (If Different From Current Address) / CITY / STATE / ZIP CODE
COUNTY / TELEPHONE #
( ) / CELL#
( ) / DATE OF BIRTH / EMAIL ADDRESS
GENDER
5 MALE
5 FEMALE
U.S. MILITARY VETERAN?
5 YES 5 NO / CONTACT PERSON’S NAME AND TELEPHONE NUMBER
(SOMEONE WHOSE PHONE NUMBER IS DIFFERENT THAN
YOURS WHO WOULD BE ABLE TO GIVE YOU A MESSAGE)
Name: ______
Relationship: ______
Number: (______)______
Contact Person NOT Living in your home
Name: ______
Relationship: ______
Number: (______)______
Address:______
U.S. CITIZEN?
5 YES 5 NO
If No: Do you have an Alien Registration Card?
5 YES 5 NO
EMPLOYMENT AUTHORIZATION DOCUMENT?
5 YES 5 NO / RACE (CHECK ONE OR MORE)
5 WHITE
5 BLACK OR AFRICAN AMERICAN
5 ASIAN
5 AMERICAN INDIAN / ALASKA NATIVE
5 NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER
ETHNICITY:
HISPANIC/LATINO 5 YES 5 NO
OTHER (SPECIFY) ______
Who referred you? Check / Circle one:
5Social Security Administration or Disability Determination Services
5Doctor, Hospital, Mental Health
5Law enforcement, Corrections, Court 5Job Connect, Workers’ Comp. 5Rehabilitation program in your community 5Welfare or public assistance agency
5University, College, or Vocational school 5Grade school or high school
5Self-referral, Friend, Family 5Veteran’s Administration 5Other______
Please check one of the following which best describes your current living arrangement:
5 Private residence (On your own, with family or roommate) 5 Group home
5 Rehabilitation facility 5 Mental health facility 5 Nursing home
5 Jail/Adult correctional facility 5 Halfway house 5 Homeless/shelter 5 Substance abuse treatment center 5 Other
Would you like to register to vote today
5 Yes 5 No Form#______
Please select one:
5Currently registered 5Not Eligible 5Not Interested / MARITAL STATUS
5 SINGLE 5 MARRIED
5 SEPARATED
5 DIVORCED 5 WIDOWED
House hold Information:
Number in Family ______Number of Dependants _____
Parents monthly income if under age 18 ______
House hold members:
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:
5Your personal income (earnings, interest, dividends, rent)
5Your spouse’s income, or support from family and friends
5Public support such as SSDI, SSI, TANF, etc.
5Other sources such as insurance or charities
RECEIVED BY:
Agency Representative : ______
IDENTIFICATION
Provide verification for the following identification: / One (1) Item from List A
OR
One (1) Item from List B
AND
One (1) Item from List C
List A
· United States Passport
· Certificate of United States Citizenship
· Certificate of Naturalization
· Unexpired Foreign Passport w/Attached Employment Authorization
· Alien Registration Card w/Photograph / List B
· State issued Driver’s License or State I.D. Card w/Picture or Information (Name, Sex, Date of Birth, Height, Weight & Color of Eyes)
· U.S. Military I.D. Card AND
List C
· Original Social Security to be Witnessed at Intake
· Birth Certificate Issued by State, County or Municipal Authority
· Unexpired INS Employment Authorization
What is your highest level of education? Check one:
5 No formal schooling
5 Some elementary school (grades 1-8)
5 Some high school (grades 9-12) but no high school diploma
5 Special education certificate of completion/attendance
5 High school diploma
5 GED (high school equivalency certificate)
Name of High School ______
5 Some college/vo-tech – No degree
Present Grade ______
5 Vocational/Technical Certificate
5 Associate Degree
5 Bachelor’s Degree
5 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:
5H.S. Student 5Other Student 5Trainee/Intern/Volunteer 5Other______5Not Employed
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.
5SSDI (Social Security Disability Insurance) Amount: $______
5General Assistance (Public Assistance) Amount: $______
5SSI (Supplemental Security Income) Amount: $______
5Veterans’ disability benefits Amount: $______
5TANF (Temporary Assistance for Needy Families) Amount: $______
5Any other public support Amount: $______
5Workers’ compensation Amount: $______(Please describe)______
______
______
Do you have any of the following types of medical insurance coverage? Check one or more:
5 Medicaid
5 Medicare
5 Workers’ Compensation
5 Private insurance through employment
5 Insurance Company______
5 No Medical Insurance Coverage
5 Other Public Insurance ______
Private insurance through other means:
(for example, insurance through your parents or spouse) / To help us coordinate your services, please check any other services you are receiving. Check one or more if you are receiving the following:
5Temporary Assistance (TANF) $______
5General Assistance (GA) $______
5Food Stamps $______
5Children and Family Services
5Foster Care
5Child Support Enforcement
5Child Care 5Adult Protective Services
5Low Income Energy Assistance
5Medicaid
5Working Healthy
5Other______
5None
COMMUNICATION ACCOMMODATIONS
5 Regular print
5 Braille
5 Other language (specify)
5 Large print / While in school, did you ever have an Individualized Education Program or IEP (special education)?
5 YES 5 NO
What is your primary means of transportation?
5 Personal Vehicle
5 Public Transportation
5 Other ______/ Have you ever been convicted of a felony?
5 Yes 5 No
Details:______
______
Probation Officer: ______
Phone # (____)______
WORK HISTORY 5 Check here if no work history
If currently working how many hours per week do you work? ______
Hourly Wage: ______
List current or last job first. If you 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
5 AIDS/HIV
5 Deaf - Blind
5 Alcohol or Other Drug Disorder
5 Deaf or Hard of Hearing
5 Post Paraplegia or Quadriplegic
5 Amputation
5 Depression
5 Post Traumatic Stress Disorder
5 Arthritis
5 Diabetes
5 Respiratory/Pulmonary/Allergies
5 Attention Deficit Disorder
5 Epilepsy
5 Severe Arthritis
5 Autism
5 Fibromyalgia
5 Specific Learning Disability
5 Back Injury
5 Heart Disease
5 Spinal Cord Injury
5 Blindness or Visual Impairment
5 Hemophilia
5 Stroke
5 Brain Injury
5 Hip/Knee, Other Joint
5 Cancer Dysfunction
5 Carpal Tunnel
5 Kidney Failure ______(Repetitive Use Syndrome)
5 Mental Illness ______
5 Cerebral Palsy (CP)
5 Muscular Dystrophy
5 Cognitive Disability
5 Multiple Sclerosis ______
5 Cystic Fibrosis
5 Myofascial Disorder
5 Unknown ______
5 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. All personal information in the possession of the Bureau may be used only for the 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:
· When a properly signed Release of Information form, conditioned and dated, is presented, or;
· For purposes directly connected with the provision of services and/or the administration of the rehabilitation program under which services are provided.
· For reasons in accordance with the stated regulations and/or any other applicable federal law, state law, policy or regulation
· BVR/BSBVI may share information with Job Connect Partners for the purpose of scheduling individuals who are seen at the Job Connect offices or to assist individuals with their job search.
· For the purpose of program cost reimbursement from the SSA, effective for an extended period of time beyond case closure
BVR/BSBVI may provide specific information to other Job Connect Partners when working in collaboration with the partner on behalf of the individual. The Job Connect partners sign confidentiality agreements in which they agree to keep all information provided to them confidential.
I understand and agree with the exchange of information with Job Connect partners for the purpose of scheduling, collaboration and job placement activities.
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
INACCURATE OR MISLEADING INFORMATION
If you believe that information in your record of services is inaccurate or misleading, you may request that the Bureau of Vocational Rehabilitation amend the information. If the information is not amended, the request for an amendment must be documented in the record of services.
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.
PRIOR AUTHORIZATION STATEMENT
I understand the Bureau of Vocational Rehabilitation will not pay for any service which my counselor HAS NOT AUTHORIZED IN WRITING. If my counselor approves a medical examination, this is NOT approval for treatment or surgery. When a doctor, hospital, merchant or other vendor has not received advance approval from my counselor, I understand I may have to pay for any goods or services myself.
CLIENT 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. I will not be required to participate in the cost of diagnostic services to evaluate my rehabilitation potential, counseling guidance and referral services, or placement services.
In making this application for vocational rehabilitation services, I acknowledge that:
· I am applying for vocational rehabilitation services for the specific purpose of getting and/or keeping a job
· It is my responsibility to inform my counselor of any changes related to this application, such as changes in my address, income or employment.
· Prior written approval from my counselor is needed before Rehabilitation Services will pay for any services.
· Payment for some services may be based on financial need according to my personal or family income.
· 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.
· 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.
ACKNOWLEDGEMENT OF ACCEPTANCE
Please place your initials beside each title of the document you have received.
______I have been informed about the protection, use and release of personal information.
______I have been informed of my opportunity for review of decisions made by my Rehabilitation Counselor regarding the furnishing or denial of service.
______I have been informed that if I do not agree with a determination by the Rehabilitation Counselor regarding my application, eligibility and services, that I have the right to have that determination reviewed.
______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 and have been provided a copy of The Participant Bill of Rights.
______
Applicant Signature Date Parent/Guardian/Legal Rep Signature
Parent/Guardian/Legal Representative’s Address _______
Telephone Number ______
Email address ______
Signature of person who filled out the application if different than above ______