Vocational Rehabilitation Services Application McKenzie Ramer

Vocational Rehabilitation www.okdrs.gov

Vocational Rehabilitation Services Application

McKenzie Ramer Carl Albert Executive Fellow

1400 Hoppe Blvd, Ste. A Phone/TTY (580) 3105300

Ada, OK 74820 Toll Free: (800) 437 4042

[email protected] Fax: (580) 310-5350

Please be advised that DRS is an EMPLOYMENT agency for people with disabilities. Our goal is to assist individuals with disabilities in their search for employment that matches their interests and abilities.

Once you have completed the application, please call to schedule an appointment. Do not sign or date the application until you meet with the counselor to complete an initial interview.

If your primary disability is a visual impairment, please call (580)3 10-5301 to reach the office that can assist you with services.

Current documentation of your disability is required to determine eligibility for vocational rehabilitation services. If you can bring these records with you, it will expedite the process. If you receive SSI or SSDI, please bring

verification of your current Social Security benefits.

Please wait to sign and date these forms until you meet with counselor.

Thank you,

Empower Oklahomans with Disabilities

1400 Hoppe Blvd Ste A Ada, Ok 74820 I Office: 580-310-5300 I Fax: 580-310-5350

Director Noel Tyler Commissioners Emily Cheng, April Danahy and Jack Tucker


Certification of Intent to Pursue Employment

I am applying for services with the Oklahoma Department of Rehabilitation Services. I must have a documented physical or mental disability that causes an impediment to obtaining and/or maintaining gainful employment.

I understand that in order to be eligible for this program and receive services, I must intend to work progressively toward obtaining/maintaining suitable employment. I understand that all services provided by this program are for the sole purpose of obtaining EMPLOYMENT.

I certify that it is my full intent to work with my Vocational Rehabilitation Counselor to establish an Individualized Plan of Employment (IPE) that will outline the goals and objectives I need to meet in order to obtain/maintain suitable employment.

I understand that once I obtain employment, I will be expected to provide my Vocational Rehabilitation Counselor with information regarding the weekly wage I am earning, name and address of employer, and dates of employment. I understand that this information will be used for reporting purposes only and that my personal information will NOT be submitted without my written permission.

I also understand that AFTER 90 days of employment, my case with the Oklahoma Department of Rehabilitation services will be closed successfully. I understand that post-employment services may be available after successful case closure if needed to maintain employment.

Client Name (Printed)

Client Signature Date


1400 Hoppe Blvd Ste A Ada, Ok 74820 Office: 580-310-5300 I Fax: 580-310-5350

Director Noel Tyler Commissioners Emily Cheng, April Danahy and Jack Tucker

(Alahoma Dep of Rehabilitation


IIV,CPORTANTI,

All persons making application to the Oklahoma Department of Rehabilitation Services are asked to watch the video "What You Need To Know About Oklahoma Vocational Rehabilitation and Visual Services" before your initial interview meeting with a counselor, If you have access to a computer, you may watch this video by following the instructions below,

1, Go to the Web Site WW1 ,okdrs, ov 2 Click on Information in the left-hand column of the screen 3, Under Information, click on Video Links 4, In the center of the page, click on Informational Videos 5. Click on What You Need to Know About Oklahoma Vocational

Rehabilitation and Visual Services to watch the video

If you are unable to watch the video prior to your appointment, you must arrive at least 15 minutes early to allow time for viewing of the video,

Yes, I have watched the video described above,

Signature Date_

No, I have not watched the video yet.

Signature Date


1400 Hoppe Blvd., Ste. A, Ada, OK 74820 I Office: 580-310-5300 I Fax: 580-310-5350

Director Noel Tyler

Commissioners Emily Cheng, April Danahy and Jack Tucker

OKLAHOMA DEPARTMENT OF REHABILITATION SERVICES CLIENT INFORMATION FORM

SSN

Last Name

Home Address

First Name

Middle Initial

(Street, Route, P.O. Box #, etc.)

City: State:

County:

Do you live in a private residence? 0 yes no

If No, Please Describe:

Mailing Address if different from above:

Directions to Home:

- Zip:

RACE & ETHNICITY: If Hispanic or Latino check more than one. Ex: Hispanic & American Indian

Black or African American

American Indian or Alaska Native

Hispanic or Latino

Native Hawaiian or other Pacific Islander

White

Asian

Please indicate below if you require an alternate correspondence format:

0 Audio Tape Braille Large Print Other

If you will you require any other accommodations, please describe.

Marital Status: divorced married n never married 0 separated [7 widowed

Who referred you to us?

REVISED 5/2015 DRS-C-1(a)

Self

DRS-C-1(a), page 2

List three people whom we may contact in an attempt to locate you, should your current contact information become outdated.

1. Last Name:

Relationship:

Home phone:

E-Mail address:

2. Last Name:

Relationship:

Home phone:

E-Mail address:

3. Last Name:

Relationship:

Home phone:

E-Mail address:

First Name:

Address/City

Cell or work phone:

First Name:

Address/City

Cell or work phone:

First Name:

Address/City

Cell or work phone:

Number of family living in your household:

LIST ALL HOUSEHOLD MEMBERS WITH INCOME INFORMATION (Include Wages, SSI, SSDI, TANF, Worker's Comp., Unemployment, etc.)

Name Relationship Source of Income Monthly Amount

Please check if you have:

ri Medicare Medicaid I I Private Insurance through own employment

Li Private Insurance through other means I I Public insurance from other sources ri None

Primary Insurance Carrier

Policy Number

Medicaid Number

REVISED 5/2015

Medicare Number

DRS-C-1(a)

OKLAHOMA DEPARTMENT OF REHABILITATION SERVICES VOCATIONAL REHABILITATION AND VISUAL SERVICES APPLICATION

Name SSN

Home Phone Number

Home Address

Email Address

Cell Phone Number

City, State, Zip

What is your disability?

Onset of Disability I- Male (1 Female Date of Birth:

Describe how your disability impairs your ability to work (or to live independently)?

(n) I am interested in assistance in obtaining employment

(0) I am interested in assistance in keeping the job I have

For individuals age 55 or older who are blind or visually impaired please check your preference:

(n) I am not interested in working, however I am interested in assistance in living independently

What type of employment are you interested in, and how can we help you achieve your goal?

Have you ever applied for rehabilitation services? n yes when? n no

Do you receive SSI or SSDI Benefits? yes no

Have you ever been convicted of a felony? H yes no Have you ever defaulted on a student loan? H yes no

My completion of this document constitutes an application for Rehabilitation Services. In order to effect my rehabilitation, I authorize the release of confidential information from my case file to agencies or others who have adopted regulations for confidentiality. All information both medical and personal given or made available to the agency shall be held to be confidential. Use of such information will be limited to purposes directly connected with the administration of my rehabilitation program. All mandatory information is collected under the authority of the Rehabilitation Act of 1973 as amended; Title 56, Oklahoma Statute 1971, sections 328 through 330 and Title 51 Oklahoma Statute 1985, Section 24A.1 through 24A.18. Failure to provide this information may prevent the rehabilitation agency from providing services in a timely manner. Otherwise, information will not be disclosed to any individual, agency or organizations without my written consent or that of my parent, guardian or representative as applicable.

I attest under penalty of perjury that I am (check one of the following)

T1 A Citizen or national of the U.S. I I A Lawful Permanent Resident L An Alien authorized to work

Information provided is subject to verification through the Social Security Administration.

Client Parent/Guardian/ Representative Date

Date

REV DATE 5/2015 DRS-C-1

DRS-C-1 (a), page 3

Level of Education attained at time of this application:

Have you received services under an Individualized Education Program (IEP)? yes ri no

High School City and State Highest Grade Dates

Completed Attended Area of Study Graduated?

Hours, Degree, or Certificate

Earned

il yes — no

College (Most Recent)

I I yes — no

Technical

IT yes 1-1 no

Other Training

IT yes E no

REVISED 5/2015 DRS-C-1 (a)

List Your Last Three Jobs Weekly Hours Employer Name Employer Address and Salary

Dates of Reason for Disability-Related Employment Leaving Problems Affecting Job

DRS-C-1(a), page 4

Job Title

Most Recent Job 1.

2.

3.

Other Work Experience

Are you a Veteran? Li yes I I no

Are you currently receiving services from an American Indian Tribal VR Program? 0 yes Li no

Are you currently receiving services from Hissom? 7 yes Limo

REVISED 5/2015 DRS-C-1 (a)

DRS-C-1, PAGE 2

VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES (56 O.S. § 71)

Statement Under Penalty of Perjury (12 O.S. § 426)

(D.O.B.) , hereby state as follows: (Applicant)

I am a United States Citizen.

I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct.

Date County

[Signature of Applicant]

(D.O.t.) , hereby state as follows: (Applicant)

I am a qualified alien under the federal Immigration and Naturalization Act, and I am lawfully present in the United States.

I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct.

Date County

[Signature of Applicant]


IF YES, HAS IT KEPT YOU FROM WORKING?

YES NO fin

fl

YES NO n

fl

n

OKLAHOMA DEPARTMENT OF REHABILITATION SERVICES GENERAL HEALTH CHECKLIST

Full Name Social Security Number

Date of Birth Height Weight

Please answer "Yes" or "No" to all items.

Do you have.. . 1. A disorder of eyes, ears, nose or throat?

2. Frequent dizziness, fainting, or headache; seizures, convulsions, paralysis, or stroke?

3. A mental or nervous disorder?

4. Persistent coughing, bronchitis, asthma, emphysema, tuberculosis, or other disorder of your lungs?

5. Chest pain, high blood pressure, rheumatic fever, murmur, heart attack, or other disorder of the heart or blood vessels?

6. Intestinal bleeding, ulcer, hernia, colitis, other disorder of the stomach, intestines, liver, or gallbladder?

7. Disorder of kidney, bladder, prostate or reproductive system?

8. Diabetes, thyroid, or other endocrine disorders?

9. Arthritis or other disorder of the muscles or bones, including the spine, back or joints?

10. Absence or amputation of any body part?

11. Loss of use of arms and legs or other body part?

12. A tumor, cancer, or disorder of skin or lymph glands?

13. Allergies?

14. Anemia or other disorder of the blood?

15. Excessive use of alcohol or any habit-forming drugs?

16. Any other physical or mental condition?

If yes, specify:

ISSUE DATE 10/01/2000 DRS-C-2

DRS-C-2, page 2

17. Name and address of your personal physician/clinic: (if none, so state)

PLEASE ANSWER THESE QUESTIONS FOR ANY CONDITION MARKED "YES" ON THE FIRST PAGE:

18. Have you been or are you being treated for any of these conditions? P YES ri NO

If No, why not?

If YES, Condition Dr. Name & Address Phone Number Dates Seen

19. Have you been hospitalized for any of these conditions? P YES n NO

If YES, Condition Hospital When?

20. Are you taking any medicines? n YES ri NO If YES, Condition Medicine Condition Medicine

21. Do you have any restrictions from these conditions? ri YES I— NO

If YES, Condition What restrictions?

To the best of my knowledge, what I have said is true and I have not withheld any information.

(Date) (Signature of applicant)

Person who provided information, if not applicant: Comments:

ISSUE DATE 10/01/2000 DRS-C-2

OKLAHOMA DEPARTMENT OF REHABILITATION SERVICES

RESPONSIBILITIES OF CLIENTS ATTENDING HIGHER EDUCATION

The following list of requirements is the responsibility of each client.

1. I will meet with my counselor each semester prior to the 100 % refund add/drop deadline and provide required enrollment documentation for that semester. 'If attending private or out-of-state college/university training, I will meet with my counselor and submit all required enrollment documentation prior to the first day of class.

2. I understand that DRS will not be responsible for any cost of my training if I fail to comply with the responsibility identified above.

3. I will enroll in a minimum of 12 hours per semester (applies to Undergraduate Fall and Spring semesters) unless other prior arrangements are approved by my counselor.

4. I will maintain a cumulative 2.00 GPA (grade point average) to continue to receive training assistance from OKDRS. If my GPA falls below 2.00 GPA, I will contact my counselor immediately.

5. I will apply for FAFSA each year and I will provide a copy of my financial aid award/denial letter to my counselor each semester when I submit my enrollment documentation.

6. I will speak with my Counselor prior to changing my major and I will notify my counselor immediately if I need to change my enrollment status.

7. I understand that I am responsible for any drop/add or late enrollment fees.

8. I will be responsible during the following enrollment period for any costs associated with failure to earn credit for any class in which I am enrolled. This includes failing a class, auditing a class, drop/add fees, late fees, duplication of a class, or withdrawal from a class.

9. I will provide my counselor with a degree check from the training institution after completing 30 hours if my degree program is for an Associate's degree or after completion of 64 hours if my degree program is for a Bachelor's degree.

I, the undersigned, have read and understand the above statements.

Signature Date

REVISED DATE 08/2016 DRS-C-050

OKLAHOMA DEPARTMENT OF REHABILITATION SERVICES EXCLUSIVE USE AFFIDAVIT

WITH REGARD TO ALL MONEY DISBURSED DIRECTLY TO ME BY THE

DEPARTMENT OF REHABILITATION SERVICES (DRS), I hereby agree to use such

money only for the purposes and in the manner explicitly identified in my Individual

Plan for Employment. I agree to submit receipts and/or other appropriate verification

as identified by my Counselor. If I use any amount of such money for any other

purpose or in any other manner or fail to provide receipts/verifications, then I agree to

reimburse DRS immediately such amount. If I fail to reimburse DRS, I understand that

DRS may use any and all legal means available to recover such amounts from me.

Signed this the day of

Signature of Consumer


Voter Registration Statement

NAME: (Please Print)

If you are not registered to vote where you live now, would you like to apply to register to vote here today?

YES III NO

If you do not check either box, you will be considered to have decided not to register to vote at this time.

Signature: Date:

1. Applying or declining to apply to register to vote will not affect the amount of assistance that you will be provided by this agency.

2. If you want help filling out the voter registration application form, we will help you. The decision to seek help is yours. You may fill out the farm here in private or you may take it with you to fill out later.

3. If you decline to apply to register to vote, the fact that you have declined will remain confidential and will be used only for voter registration purposes.

4. If you apply to register to vote, the location at which you submit your application form will remain confidential and will be used only for voter registration purposes.

5. If you do not check a box on this form and/or refuse to sign this form, you will be given a copy of the voter registration application form to take with you when you leave today.

6. If you believe that someone has interfered with your right to register or to decline to register to vote, with your right to privacy in deciding whether to register or in applying to register, or with your right to choose your own political party or other political preference, you may make a complaint to the Oklahoma State Election Board. Mailing Address: Oklahoma State Election Board, PO Box 53156, Oklahoma City, OK 73152 E-mail address: [email protected]

Telephone: (405) 521-2391

7. If you fill out the application form here today, we will accept it and submit it to election officials for you. If you take the form with you to fill out later, you can return it here. We will accept and submit it for you, or you can mail it to the State Election Board yourself.

SEB-3/1/15

im

OK DEPT OF REHABILITATION SERVICES

AUTHORIZATION TO DISCLOSE INFORMATION

I SS# DOB: (Client's name)

voluntarily request and authorize (doctor, psychologist, hosp, clinic, agency or school)

to disclose my medical records to:

Name: Department of Rehabilitation

ATTN: McKenzie Ramer

Address: 1400 Hoppe Blvd, Ste A

City, State, Zip Code: Ada, OK 74820 Fax 580-310-5350

The specific type of information to be disclosed is: (check one or more as applicable)

0 ALL MEDICAL RECORDS REGARDING MY TREATMENT, HOSPITALIZATION AND/OR OUTPATIENT CARE

[7 ALL PSYCHOLOGICAL OR PSYCHIATRIC RECORDS E. ALL VOCATIONAL RECORDS

LI OTHER, AS SPECIFIED: Past two years of records- NO X-Rays or LABS

The purpose and need for the disclosure is to: KI Establish the individual's eligibility for the vocational rehab program for individuals with disabilities

that constitute a substantial impediment to employment. Iii Assess the vocational rehabilitation needs of the individual for the purposes of developing a

vocational rehabilitation plan. Ki Determine the need for and/or type of treatment for the individual as part of the individual's vocational

rehabilitation plan. ii] Other (specify):

The information I authorize for release may include records which may indicate the presence of a communicable or non-communicable disease. I understand that these records may include psychiatric, alcohol and drug abuse information, occupation information, or information regarding other insurance coverage. I specifically authorize the release of my drug, alcohol and/or mental health treatment records.

I understand that the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient, and is no longer protected under the HIPAA Privacy Rule. The Department of Rehabilitation Services is required by federal and state law to maintain the confidentiality of the information with some exceptions: 34 CFR § 361.38 qnd OAC 612:10-1-5.

RIGHT TO REVOKE; I may revoke this authorization by sending a written request to the Department of Rehabilitation Services, 3535 NW 58th, Suite 500, OKC, OK 73112, except revocation will not apply to information already retained, used or disclosed in response to this authorization.

TERMINATION DATE: This authorization expires twelve (12) months following the date signed by me.

Signature: Date:

If not signed by client, specify basis for authority to sign on client's behalf: 0 0 Ell Parent Guardian Representative

REV DATE 09/19/2016 DRS-C-5

OK DEPT OF REHABILITATION SERVICES AUTHORIZATION TO DISCLOSE INFORMATION

I SS# DOB: (Client's name)

voluntarily request and authorize (doctor, psychologist, hosp, clinic, agency or school)

to disclose my medical records to:

Name: Department of Rehabilitation

ATTN: McKenzie Ramer

Address: 1400 Hoppe Blvd, Ste A

City, State, Zip Code: Ada, OK 74820 Fax 580-310-5350

The specific type of information to be disclosed is: (check one or more as applicable)

ID ALL MEDICAL RECORDS REGARDING MY TREATMENT, HOSPITALIZATION AND/OR OUTPATIENT CARE

EI ALL PSYCHOLOGICAL OR PSYCHIATRIC RECORDS El ALL VOCATIONAL RECORDS Y OTHER, AS SPECIFIED: Past two years of records- NO X-Rays or LABS

The purpose and need for the disclosure is to: y Establish the individual's eligibility for the vocational rehab program for individuals with disabilities

that constitute a substantial impediment to employment. ID Assess the vocational rehabilitation needs of the individual for the purposes of developing a

vocational rehabilitation plan. Ei Determine the need for and/or type of treatment for the individual as part of the individual's vocational

rehabilitation plan. El Other (specify):

The information I authorize for release may include records which may indicate the presence of a communicable or non-communicable disease. I understand that these records may include psychiatric, alcohol and drug abuse information, occupation information, or information regarding other insurance coverage. I specifically authorize the release of my drug, alcohol and/or mental health treatment records.

I understand that the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient, and is no longer protected under the HIPAA Privacy Rule. The Department of Rehabilitation Services is required by federal and state law to maintain the confidentiality of the information with some exceptions: 34 CFR § 361.38 qnd OAC 612:10-1-5.

RIGHT TO REVOKE; I may revoke this authorization by sending a written request to the Department of Rehabilitation Services, 3535 NW 58th, Suite 500, OKC, OK 73112, except revocation will not apply to information already retained, used or disclosed in response to this authorization.

TERMINATION DATE: This authorization expires twelve (12) months following the date signed by me.

Signature: Date:

If not signed by client, specify basis for authority to sign on client's behalf: 0 ci Li Parent Guardian Representative

REV DATE 09/19/2016 DRS-C-5

Professional Disclosure Form — Oklahoma Department of Rehabilitation Services

The purpose of public vocational rehabilitation is to assist eligible persons with disabilities in achieving an employment outcome. This outcome may be returning to your former job or obtaining a job in a new field. You and your counselor will work together to find a job that you are physically and mentally able to do that is as close as possible to your vocational goals.

You will be working with a person who is a qualified rehabilitation counselor (RC) or is being supervised by one. You will be assigned a RC. If you are not satisfied at any time, you can inform your RC, his/her supervisor, or the state agency that handles such complaints. If you feel the RC has acted in an unethical manner, you should contact the Commission on Rehabilitation Counselor Certification.

To be eligible for vocational rehabilitation services, you may first be asked to take part in an evaluation. As much as possible, your RC will use information already available in your file. However, your RC may need you to sign a release of information form so that more information can be gathered. Additional tests, exams, or evaluations may be necessary to determine if you qualify for vocational rehabilitation services.

If you are eligible for vocational rehabilitation services, you and your RC will jointly develop an Individual Plan of Employment (IPE). The IPE spells out your vocational goals and the services that will be provided in order to help you reach those goals. It is important that you exercise your consumer choice by actively participating in the development of the IPE. Some of the services that may become a part of the IPE include the items listed below. Your RC will explain each service to you.

• Evaluation for vocational rehabilitation needs

• Physical restoration

• Counseling and guidance

• Supported employment

• Educational training

• Assistive technology, services, and equipment

• Job development and placement

• Employment retention and follow-up services

The types of services provided will depend on your particular needs. You and your RC are expected to work together to identify the comprehensive services that you will need. The timeframe of your IPE depends upon your goals and your progress. Your IPE can be reviewed and changed by you and your RC as appropriate.

This disclosure form is provided by the Commission on Rehabilitation Counselor Certification (CRCC) as a sample of the content that would be appropriate to include in a disclosure form for the public sector. The form must be reviewed for applicability to each particular case and appropriate modifications must be made.

Page 1 of 3 Developed 08/2002 — Revised 08/2009

One very important part of your relationship with your RC is confidentiality. Personal information related to your rehabilitation services may be recorded in your file. This information will be kept private except as follows:

• If you have signed a release of information form that allows information to be shared. That form will state who receives what information. While your signature is voluntary, you need to be aware that your decision not to sign means that information cannot be shared with other providers. Thus, it may impact the implementation of your IPE.

• If your RC believes you are going to harm or endanger yourself or others, he/she is required to notify the endangered individual(s), the proper authorities and/or officials.

• If your RC believes you are going to harm or endanger or abuse children or the elderly, he/she must report this to state or local authorities.

• If your RC or this agency is sued or court ordered and a properly issued subpoena is received, then information in your file may be released.

• If you are a minor or not your own legal guardian, then the information in your file may be available to your legal guardian or advocate.

It is important to remember that the goal of the RC is to help you secure a satisfactory job and that services must be related to that goal. It is also important to know that the RC will, at all times, try to act in your best interest and protect you from unnecessary risk.

Before signing this form, your RC will review the following topics with you.

• The RC's roles and responsibilities

> Your roles and responsibilities

)=. The RC's approach or method

> Legal issues affecting services

• Confidentiality and limitations regarding confidentiality

• Creating and using the IPE

> Goals and types of services provided

> Types of services not provided

> Risks and benefits associated with services

> Who to contact in the event the RC is unavailable



By signing this form, I attest that I have discussed the aforementioned topics with my RC and that I understand the information discussed as well as the information contained within this document.

Signature of Client Date

Printed Name of Client

Signature of Legal Guardian Date

Printed Name cg Legal Guardja43

klINAa

Signature of Reha itation Counselor Date

Printed Name of Rehabilitation Counselor

RECOMMENDED CITATION

Commission on Rehabilitation Counselor Certification. (2009). Professional Disclosure Form — Public Sector Example. Retrieved [date] from, http://www.crccertification.com/filebin/pdf/CRCC_Public_DisclosureForm.doc



Work History

._ I. have at least a fair work history.

I have a poor work history.

Education or Occupational Skiffs Attainment

I have at least fair job skills.

I have limited job skills.

Encrfish Proficiency

I have functional English proficiency.

I speak poor English. My native language is not English and I have limited ability in speaking, reading, writing, or understanding the English language.

Literacy Skiffs

I have functional literacy.

I have low literacy (compute or solve problems, read, write, or speak English at or below the 8th grade level).

Cultural Barriers

I have no cultural barriers.

I have significant cultural barriers

Basic Skills

I have no significant deficits of basic skills.

I am unable to compute or solve problems, read, write or speak English at a level necessary to function on a job.

Dislocation from Hicrh-Waae and Flioh-Benefft Employment

I have recently been dislocated from a high-wage, high benefit job.

I have not recently been dislocated from a high-wage, high benefit job.

Sinole Parent

I am a single parent.

I am not a single parent.

Displaced Homemaker

I have been dependent on the income of another family member but am no longer sctnported by that income.

.Does not apply.

Low Income

I have an income above the poverty level, or pm a member of a family whose combined income is above the poverty lev-el, and do not qualify for most public assistance programs (TANF, Food Stamps, etc).

I have an income below the poverty level, or am a member of a family whose corribined income is below the.poverty level, and May qualify for income based public assistance program such as (SSI, TANF, Food Stamps, etc).

Dislocated Worker

I have recently been laid off of a job because of a reduction in the employer's workforce or have been self-employed and am now unemployed due to general economic conditions or a natural disaster.

Does not apply.

Foster Care Youth

\ I have never been in foster care.

I have been placed in foster care or have aged out of foster care.

TANF

I will exhaust TANF within 2 years: Yes No I do not receive TANF

Felony Convictions

Offense

Date of Conviction State where conviction occurred.

Offense

Date of Conviction

Offense

State where conviction occurred

Date of Conviction

Offense

State where conviction occurred

Date of Conviction State where conviction occurred

Use the back of the page to add additional felony convictions if needed.

Invovement with Other Apenc5es and Services At ApDHcatfrm Checkbox Ust***

American Indian VR Services Program - Center for Independent Living

Child Protective Services Community Rehabilitation Program

Consumer Organization or Advocacy Educational Institution Group (elementary/secondary)

- Educational Institution (post-secondary)

✓ Employment Network (not otherwise Federal Student Aid (Pell grant, SEOG, listed) work study, etc.)

• Intellectual and Developmental Disabilities Agency

7 Mental Health Provider (public or - No Service or Funding Provided private)

One-stop Employment/Training Center Other Source

Other State Agency

Public Housing Authority

r: State Department of Correction/Juvenile Justice

— Veterans Administration

Workers Compensation

• Other VR State Agency

• SSA (Disability Determination Service or

district office)

• State Employment Service Agency

• Welfare Agency (state or local government)

Employer

• Medical Health Provider_ (public or private)

Vocational Rehabilitation Services Application McKenzie Ramer

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