NevadaDepartmentofEmployment,Training and Rehabilitation

Applicationfor Vocational RehabilitationService

Case#_
LAST NAME / FIRST NAME / MIDDLE INITIAL / PREVIOUS NAMES USED / SOCIALSECURITY#
X X X - X X - ______
CURRENT STREET ADDRESS / Apt# / CITY / STATE / ZIP CODE
MAILING ADDRESS (IfDifferent From Current Address) / CITY / STATE / ZIP CODE
COUNTY / TELEPHONE#
() / CELL#
() / DATE OF BIRTH / EMAIL ADDRESS
GENDERMALE
FEMALE
U.S.MILITARYVETERAN?
  YES NO / CONTACTPERSON’SNAME AND TELEPHONE NUMBER (SOMEONEWHOSEPHONE NUMBER IS DIFFERENTTHAN YOURS WHO WOULD BE ABLE TO GIVE YOUA MESSAGE)
Name: Relationship: Number: _()
ContactPersonNOT Livingin yourhome
Name: Relationship: Number:_( ) Address:_
U.S.CITIZEN?YES NO
If No:DoyouhaveanAlienRegistrationCard?
YES NO
EMPLOYMENTAUTHORIZATION DOCUMENT?YES NO / RACE(CHECKONEORMORE)
WHITEBLACKOR AFRICANAMERICAN ASIAN
AMERICANINDIAN/ ALASKANATIVENATIVEHAWAIIAN/OTHERPACIFICISLANDER
ETHNICITY: HISPANIC/LATINO YES NO OTHER(SPECIFY)
Who referred you?Check/Circleone:
SocialSecurityAdministration or DisabilityDeterminationServicesDoctor, Hospital,MentalHealth
Lawenforcement,Corrections, CourtJob Connect, Workers’Comp. Rehabilitation program in your community
University, College,or VocationalschoolSelf-referral,Friend, FamilyWelfare orpublicassistance agency
Gradeschoolor highschoolVeteran’sAdministrationOther
Please check one of the following which bestdescribesyourcurrent living arrangement:
Private residence(On your own, withfamily orroommate)GrouphomeRehabilitation facility Other
Mentalhealth facilityNursinghomeJail/Adultcorrectionalfacility
Substance abusetreatmentcenterHalfwayhouseHomeless/shelter
Wouldyouliketoregistertovotetoday YesNo Form#
Pleaseselect one: CurrentlyregisteredNotEligibleNotInterested / MARITALSTATUSSINGLEMARRIED
SEPARATED DIVORCED
WIDOWED
HouseholdInformation:
Numberin Family Numberof Dependents Parents monthly income if underage 18 House holdmembers:
Name: Age: Relationship: Occupation: Name: Age: Relationship: Occupation: Name: Age: Relationship: Occupation:
Name: Age: Relationship: Occupation:
What is yourprimary (largest) source of support?Monthly Amount $ Check one of the following:
Your personalincome(earnings,interest, dividends, rent)Your spouse’sincome, or support from familyand friends
PublicsupportsuchasSSDI, SSI, TANF, etc.Othersourcessuch asinsuranceorcharities
DATE RECEIVED(FOR OFFICE USEONLY)
RECEIVED BY:
AgencyRepresentative :
IDENTIFICATION / One(1) ItemfromListA
OR
One(1) ItemfromListB AND One (1) Itemfrom ListC
Provide verificationforthefollowingidentification:
List A
 UnitedStatesPassport
 CertificateofUnitedStatesCitizenship
 CertificateofNaturalization
 UnexpiredForeignPassportw/AttachedEmployment
Authorization
 AlienRegistrationCardw/Photograph / ListB
 StateissuedDriver’sLicenseorStateI.D.Card w/Picture
orInformation(Name,Sex,Dateof Birth,Height,Weight
Colorof Eyes)
 U.S.MilitaryI.D.Card
AND ListC
 OriginalSocialSecurityCardtobeWitnessedatIntake
 BirthCertificateIssuedbyState,Countyor Municipal
Authority
 UnexpiredINSEmploymentAuthorization
What is yourhighest level ofeducation? Check one:
No formalschoolingSomeelementaryschool(grades1-8)
Somehigh school(grades9-12)but nohighschooldiplomaSpecialeducation certificate ofcompletion/attendance
High schooldiplomaGED(highschoolequivalencycertificate) Nameof HighSchool_ Somecollege/voc-tech–No degree PresentGrade Vocational/TechnicalCertificate
AssociatesDegreeBachelor’sDegree
Master’sDegree or Higher
College/Vo-Tech Schools :Nameof School:
Address of School:_
How can the Bureaube ofassistance toyou? Whatemployment relatedservices are you seeking:
Are you working?If yes, where:
If no, checkone: H.S. StudentOther StudentTrainee/Intern/Volunteer
OtherNot Employed
If you are employed, howmany hours do youusually work per week?
If you are employed,what are yourcurrentWEEKLYearnings? $
(grosswages,salaries, tipsorcommissionsbefore payrollor taxdeductions)
Are you currently receivingany of the following?If yes, please list theMONTHLYamount.
SSDI(SocialSecurityDisabilityInsurance)Amount: $GeneralAssistance(PublicAssistance)Amount: $
SSI (SupplementalSecurityIncome)Amount: $Veterans’disabilitybenefitsAmount: $
TANF(TemporaryAssistance forNeedyFamilies) Amount: $AnyotherpublicsupportAmount: $
Workers’compensationAmount: $(Pleasedescribe)_
Do you have any of the following typesof medical insurance coverage?Checkone ormore:
Medicaid
Medicare
Workers’ Compensation
Private insurance throughemployment
Insurance Company
No MedicalInsurance Coverage
Other PublicInsurance
Private insurance throughother means(for example, insurance through your parentsor spouse) / To help us coordinate yourservices, please check anyother services youare receiving. Check one ormore ifyou are receiving the following:
TemporaryAssistance (TANF)$
GeneralAssistance (GA)$
Food Stamps$_Children and FamilyServices
Foster CareChildSupport Enforcement
ChildCareAdult Protective Services
LowIncome EnergyAssistanceMedicaid
Working HealthyOther
None
COMMUNICATION ACCOMMODATIONS
Regular printBraille
Otherlanguage (specify) Large print / While in school, did youeverhave an Individualized Education
Program orIEP(special education)?YESNO
What is yourprimarymeansof transportation?
PersonalVehicle PublicTransportation
Other / Have you everbeen convicted of a felony? Yes No Details: ProbationOfficer: Phone#

WORK HISTORYCheckhereifnoworkhistory

If currentlyworking howmanyhoursper weekdoyouwork?

HourlyWage:

Listcurrent orlastjobfirst.Ifyourunoutofspaceyoumay continueon the backside ofthis sheet.

Name of Employer:
Address:
JobDuties:
Title ofPositionHeld: / Dates of Employment: From: To:Mo/YrMo/Yr
Reasonforleaving:
Name of Employer:
Address:
JobDuties:
Title ofPositionHeld: / Dates of Employment: From: To:Mo/YrMo/Yr
Reasonforleaving:
Name of Employer:
Address:
JobDuties:
Title ofPositionHeld: / Dates of Employment: From: To:Mo/YrMo/Yr
Reasonforleaving:
Name of Employer:
Address:
JobDuties:
Title ofPositionHeld: / Dates of Employment: From: To:Mo/YrMo/Yr
Reasonforleaving:
Name of Employer:
Address:
JobDuties:
Title ofPositionHeld: / Dates of Employment: From: To:Mo/YrMo/Yr
Reasonforleaving:
Name of Employer:
Address:
JobDuties:
Title ofPositionHeld: / Dates of Employment: From: To:Mo/YrMo/Yr
Reasonforleaving:

DISABILITY (Check all thatapply)

Whatis theprimarymedicalcondition,injury,physical/mentalimpairmentordisabilitythatlimitsyourabilityto work?

Whendidtheseimpairments/disabilitiesbegin?

Month /Year

AIDS/HIVDeaf- Blind

Alcohol orOtherDrug DisorderDeafor HardofHearingPostParaplegia or Quadriplegic

AmputationDepressionPost TraumaticStressDisorder

ArthritisDiabetesRespiratory/Pulmonary/Allergies

AttentionDeficitDisorderEpilepsySevereArthritis

AutismFibromyalgiaSpecificLearningDisability

Back InjuryHeartDiseaseSpinal Cord Injury

BlindnessorVisual ImpairmentHemophiliaStroke

Brain InjuryHip/Knee, OtherJoint

CancerDysfunctionOther 

Carpal TunnelKidneyFailure

(Repetitive Use Syndrome / Mental Illness
 / CerebralPalsy(CP) / MuscularDystrophy / Unknown
 / Cognitive Disability / Multiple Sclerosis
 / CysticFibrosis / MyofascialDisorder

CURRENT PHYSICIAN /MEDICALPROFESSIONAL

1.NameAddress

2.NameAddress

3.Name

Address

TypeofPhysician Phone/FaxNumber TypeofPhysician Phone/FaxNumber Type ofPhysician

Phone/Fax Number

Ifadditional spaceisneeded please enter information onthe backof thispage.

HOSPITALIZATIONS

NameofHospital:Address:

Reason:

LIST OFMEDICATIONS

Name ofHospital: Address: Reason:

CONFIDENTIALPERSONALINFORMATION

TheBureauofVocationalRehabilitation isastateandfederallyfundedagencythatassistspersonswithdisabilitiesin achievingormaintainingemployment.IunderstandthatitisnecessaryfortheBureautocollectpersonalinformation in connection withmyrehabilitation program.Iunderstandthatsuchinformationwillbecollected,tothemaximumextent practicable,fromme. The Bureau may only use personal information forpurposesdirectly connectedwiththeprovisionofservicesandtheadministrationoftheprogram underwhichservicesareprovided.

Iunderstandthatinformationisavailabletomewhenrequestedinwriting,exceptwheretheBureaubelievessuch information canreasonablybeexpectedtocausephysicaloremotionalharm.Inthisinstance,theBureaushallrelease suchinformationthroughaqualifiedmedicalorpsychologicalprofessionalortoanauthorizedrepresentative. Any informationprovidedbyme issubjecttoverificationandreviewthroughtheSocialSecurityAdministration.

Iunderstand thatmyeligibility and/orprovisionofservicesmaybeimpacted ifIrefusetoprovidepersonalinformation thatisrequestedbytheBureau.

Iunderstandthatmypersonalinformation willbeheldconfidentialbytheBureauandwillnotbedisclosedtoanyother personorentityexcept as noted in the Information and Disclosure Form.

Section504(A)oftheWorkforceInvestmentActof1998;Section12coftheRehabilitationActof1973asAmended;

29USC711cand721(a)(6)(A);34CFR361.38;NRS426.573,426.610,432B.220,615.280,615.290;629.061

In making this application for vocational rehabilitation services, I acknowledge that:

  • Purpose of applying for services: I am applying for vocational rehabilitation services for the specific purpose of getting and/or keeping a job.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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 mailinformation 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. I agree to enter into a rehabilitation counseling relationship at this time.

Applicant Signature______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______