Georgia Department of Labor

Rehabilitation Services

Vocational Rehabilitation Program

8385 Cherokee Boulevard • Suite 101 • Douglasville, GA 30134-8517

Voice/TTY (770) 489-3018 • FAX (770) 489-3115

Michael L. Thurmond

Commissioner

Rehabilitation Services School System Referral Form

Section two

(To be completed following notification of initial intake for VR services)

Student Name: ______Date of Birth: ______School: ______

STUDENT BEHAVIORS

  1. Motivation to Work: ______
  1. Dependability: ______
  1. Personal Habits: ______
  1. Social Competence: ______
  1. Specific Academic Behaviors: ______
  1. Work Tolerance: ______
  1. Attendance: ______
  1. Punctuality: ______
  1. Supervisor/Authority Relations: ______
  1. Flexibility: ______
  1. Peer Interactions: ______
  1. Communication Skills: ______

WORK OBJECTIVES/ WORK HISTORY

  1. Has applicant ever worked? YES NO If yes, where? ______
  2. Has applicant participated in any type of work study program in high school (i.e. Community Based Vocational Training, Work Based Learning)? YES NO If yes, explain. ______
  3. What is the applicant’s vocational interest? ______

LIMITATIONS

Check each limitation that applies to this individual and then briefly explain the relationship of the limitations to the applicant’s ability to work:

ð  1. Ambulation - Physical ability to access one’s environment (Note: The environment cannot be the handicapping condition)

ð  2. Breathing - Ability to inhale and exhale in an unimpaired fashion.

ð  3. Cognition - Ability to focus, perceive, comprehend, process or retain information.

ð  4. Endurance/Work Tolerance - Physical or emotional ability to perform sustained work.

ð  5. Hearing- Ability to hear without amplification.

ð  6. Interpersonal Skills - Ability to interact with others in a socially acceptable manner.

ð  7. Mobility - Mental or sensory ability to access one’s environment, excluding ambulating.

ð  8. Self-Care - Ability to perform activities of daily living.

ð  9. Self-Direction - Ability to organize, structure, or manage activities.

ð  10. Speech - Verbal ability to make oneself understood by others. (Note: NOT foreign language barriers.)

ð  11. Upper/Lower Extremely Functioning - Ability to perform tasks requiring manual or pedal dexterity, excluding ambulation.

ð  12. Vision- ability to see with best correction

______

Current Medication (type/dosage): ______

Attachments - Please include the most recent:

___ IEP ___ Transition Plan ___ Discipline Record (if applicable)

___ Eligibility Report ___ Vocational Assessment(s) ___ Transcript (if applicable)

___ Psychological ___ Attendance Record ___ Other: ______

Signature: ______Date: ______

Referring Teacher

Signature: ______Date: ______

Educational Evaluator or Special Ed Department Chair (Circle one)

REHABILITATION SERVICES OFFICE USE ONLY!

Referral Accepted______

Referral Rejected ______and Why? ______

______

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An Equal Opportunity Employer/Program

RS143