VR5056 Application for Vocational Rehabilitation Services



Texas Workforce CommissionVocational Rehabilitation ServicesApplication for Services FORMTEXT ?Initial Contact Information FORMTEXT ? First contact date: FORMTEXT ????? Initial contact without case assignment date: FORMTEXT ?????Social Security number: FORMTEXT ?????Initial contact with case assignment date: FORMTEXT ?????Last name: FORMTEXT ?????First name: FORMTEXT ?????Middle Name: FORMTEXT ?????Prefix: FORMTEXT ?????Preferred Name: FORMTEXT ?????Date of birth: FORMTEXT ?????Homeless/Runaway FORMTEXT ? : FORMCHECKBOX Individual does not meet the definition of homeless FORMCHECKBOX Individual does meet the definition of homeless FORMCHECKBOX Did not self identifyAddress: FORMTEXT ?????ZIP: FORMTEXT ?????ZIP suffix: FORMTEXT ?????State: FORMTEXT ??City: FORMTEXT ?????County: FORMTEXT ?????Fips State: FORMTEXT ?????Fips County: FORMTEXT ?????Workforce Area: FORMTEXT ?????Telephone number 1: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 2: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 3: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 4: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Preferred Method of Meeting Primary: FORMCHECKBOX Face to Face FORMCHECKBOX Phone FORMCHECKBOX Virtual FORMCHECKBOX Did not Select/Disclose FORMCHECKBOX Not ApplicablePreferred Method of Meeting Secondary: FORMCHECKBOX Face to Face FORMCHECKBOX Phone FORMCHECKBOX Virtual FORMCHECKBOX Did not Select/Disclose FORMCHECKBOX Not ApplicablePreferred Method of Meeting Tertiary: FORMCHECKBOX Face to Face FORMCHECKBOX Phone FORMCHECKBOX Virtual FORMCHECKBOX Did not Select/Disclose FORMCHECKBOX Not ApplicablePreferred Method of Meeting Ongoing Contact: FORMCHECKBOX Email FORMCHECKBOX Text FORMCHECKBOX Phone FORMCHECKBOX MailCustomer has Internet: FORMCHECKBOX Yes FORMCHECKBOX NoCustomer has computer/laptop: FORMCHECKBOX Yes FORMCHECKBOX NoCustomer is able to video conference: FORMCHECKBOX Yes FORMCHECKBOX NoVideo Relap IP Address: FORMTEXT ?????Email address 1: FORMTEXT ?????Email address 2: FORMTEXT ?????Email address 3: FORMTEXT ?????Email address 4: FORMTEXT ?????Other: FORMTEXT ?????Currently Enrolled FORMTEXT ? : FORMCHECKBOX Not at this time FORMCHECKBOX Grades 7-12 FORMCHECKBOX Home School 7-12 FORMCHECKBOX Grades K-6 FORMCHECKBOX Home School K-6 FORMCHECKBOX 18+ Program in High School FORMCHECKBOX College 2 year FORMCHECKBOX College 4 year FORMCHECKBOX Graduate school/advance degree FORMCHECKBOX Vocational school for industry certification FORMCHECKBOX Training-ApprenticeshipIndividualized Education Plan: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Did not disclose504 Plan: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Did not discloseLeval of Education: FORMTEXT ?????Disaster/Incident Victim: FORMCHECKBOX Yes FORMCHECKBOX NoPopulation Indicators FORMTEXT ?: FORMCHECKBOX Blind Vocational Rehabilitation FORMCHECKBOX Veteran FORMCHECKBOX VRS Transition FORMCHECKBOX Deaf/Hard of Hearing FORMCHECKBOX Mental Health/Substance Abuse FORMCHECKBOX Neurodevelopmental FORMCHECKBOX Traumatic Brain Injury/Spinal Cord Injury FORMCHECKBOX Deafblind FORMCHECKBOX Mobility Impaired FORMCHECKBOX CCRCRace and Ethnicity FORMTEXT ?: FORMCHECKBOX American Indian or Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Black or African American FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Native Hawaiian or other Pacific Islander FORMCHECKBOX White FORMCHECKBOX Did not self-identifyCertified Degree of Indian Blood Card: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Indian and Native American Programs: FORMTEXT ?????VR Services Strategy Requested FORMTEXT ?: FORMCHECKBOX Preparing for Employment FORMCHECKBOX Obtaining Employment FORMCHECKBOX Retaining Employment FORMCHECKBOX Advancing Employment FORMCHECKBOX Exploring Older Blind Services FORMCHECKBOX Pre-ETS Services Only FORMCHECKBOX Older Blind Services Only FORMCHECKBOX Career Counseling for 511 Customers OnlyAnticipated Employment Outcome FORMTEXT ?: FORMCHECKBOX Competitive Integrated Employment FORMCHECKBOX Self-Employment FORMCHECKBOX Supported Employment FORMCHECKBOX Supported Self-EmploymentHow may we help you?: FORMTEXT ?????Referral Source FORMTEXT ?Referral Category FORMTEXT ?: FORMCHECKBOX Education Institutions-Public or Private FORMCHECKBOX Public Agencies and Organizations FORMCHECKBOX Private Organizations and Individuals FORMCHECKBOX Hospitals and Health Organizations-Public or Private Referral Source: FORMTEXT ?????Referral Source Name: FORMTEXT ?????Referral Source Address: FORMTEXT ?????ZIP: FORMTEXT ?????State: FORMTEXT ?????City: FORMTEXT ?????County: FORMTEXT ?????Referral Source Telephone number ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Personal FORMTEXT ? Gender: FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX Did not self-identifyMarital status: FORMTEXT ?????Living arrangements: FORMTEXT ?????Job Ready: FORMCHECKBOX Yes FORMCHECKBOX NoDriver’s license or state ID number: FORMTEXT ?????State: FORMTEXT ?????Language Preference: FORMTEXT ?????English Language Learner: FORMTEXT ?????Media Preference: FORMTEXT ?????Colonias: FORMCHECKBOX Yes FORMCHECKBOX NoLawsuit Pending: FORMCHECKBOX Yes FORMCHECKBOX NoCustomer has barriers related to an arrest, conviction, or other offense or delinquent act: FORMCHECKBOX Did not disclose FORMCHECKBOX No FORMCHECKBOX Yes Housed in a jail or prison at application: FORMCHECKBOX Yes FORMCHECKBOX NoIf applicable, date released from incarceration: FORMTEXT ????? Offered Voter Registration Assistance to the Customer Date: FORMTEXT ????? Immigration FORMTEXT ? Is the customer a U.S. citizen? FORMCHECKBOX Yes FORMCHECKBOX NoIs the customer an immigrant alien? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the customer have a work permit? FORMCHECKBOX Yes FORMCHECKBOX NoTexas residence: Is the customer’s current address in Texas? FORMCHECKBOX Yes FORMCHECKBOX NoEmployment Authorization FORMTEXT ? Document(s) Provided: FORMTEXT ?????Does Document(s) provided have an Expiration Date: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Expiration Date: FORMTEXT ?????Inactivate Document Provided: FORMTEXT ?????Reason Document Inactivated: FORMTEXT ?????Insurance FORMTEXT ? FORMCHECKBOX No insurance FORMCHECKBOX Medicaid FORMCHECKBOX Medicare FORMCHECKBOX Private insurance through own employment FORMCHECKBOX Private insurance through other means FORMCHECKBOX CHIP FORMCHECKBOX Texas Healthy Kids FORMCHECKBOX Children with Special Health Care Needs (CSHCN) FORMCHECKBOX Public insurance through federal means FORMCHECKBOX Public insurance through other meansMedicaid Status FORMTEXT ? Medicaid number: FORMTEXT ?????Verification source and status: FORMTEXT ?????Verification date: FORMTEXT ?????Employment FORMTEXT ? Status (select one): FORMTEXT ? FORMCHECKBOX Competitive Integrated Employment FORMCHECKBOX Self-Employed FORMCHECKBOX Randolph-Sheppard Business Enterprise Program FORMCHECKBOX Employed: State Agency-managed Business Enterprise Program FORMCHECKBOX Employed: Extended Employment FORMCHECKBOX Employed: Meets One of the Following Criteria FORMCHECKBOX Not Employed: Student in Secondary Education FORMCHECKBOX Not Employed: All Other Students FORMCHECKBOX Not Employed: Trainee, Intern or Volunteer FORMCHECKBOX Not Employed: OtherEmployed with No Earnings: FORMCHECKBOX Yes FORMCHECKBOX NoEmployment Status Type: FORMCHECKBOX Job Retention FORMCHECKBOX Career Advancement FORMCHECKBOX Not ApplicableWorkers’ Compensation FORMTEXT ?Is the customer seeking services due to an injury on the job? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the customer have a current workers' compensation case that is, receiving either medical benefits or income benefits or both? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, check all that apply below: FORMTEXT ? FORMCHECKBOX Texas Division of Workers’ Compensation FORMCHECKBOX Federal Workers’ Compensation FORMCHECKBOX Workers’ compensation agency other than Texas or federalAgency Involvement FORMTEXT ?Select up to 3 agencies or providers of services utilized by customer at application: FORMTEXT ? FORMCHECKBOX None FORMCHECKBOX Centers for Independent Living FORMCHECKBOX Child Protective Services FORMCHECKBOX Community Rehabilitation Programs FORMCHECKBOX Customer Organizations or Advocacy Groups FORMCHECKBOX Educational Institutions (elementary/secondary) FORMCHECKBOX Educational Institutions (post-secondary) FORMCHECKBOX Employers FORMCHECKBOX Employment Networks (not otherwise listed) FORMCHECKBOX Federal Student Aid (such as, Pell grants, SEOG (Supplemental Educational Opportunity Grant), work study, etc. FORMCHECKBOX Intellectual and Developmental Disabilities Agencies FORMCHECKBOX Medical Health Provider (Public or Private) FORMCHECKBOX Mental Health Provider (Public or Private) FORMCHECKBOX Local Workforce Center (One-stop Employment/Training Centers) FORMCHECKBOX Public Housing Authority FORMCHECKBOX Social Security Administration (Disability Determination Service or District office) FORMCHECKBOX State Department of Correction/Juvenile Justice FORMCHECKBOX Veterans Administration FORMCHECKBOX Welfare Agency (State or local government) FORMCHECKBOX Worker's Compensation FORMCHECKBOX Other VR State Agencies FORMCHECKBOX Other State Agencies FORMCHECKBOX Other SourcesInsurance Policy FORMTEXT ?Insurance carrier 1: FORMTEXT ?????Policy number: FORMTEXT ?????Group number: FORMTEXT ?????Insurance carrier 2: FORMTEXT ?????Policy number: FORMTEXT ?????Group number: FORMTEXT ?????Insurance carrier 3: FORMTEXT ?????Policy number: FORMTEXT ?????Group number: FORMTEXT ?????Veteran Information FORMTEXT ?Veteran Status FORMCHECKBOX Dishonorably discharged FORMCHECKBOX Any discharge other than dishonorable FORMCHECKBOX Not a veteranActive Military: FORMCHECKBOX Yes FORMCHECKBOX NoMilitary State Postal Code: FORMTEXT ?????Transitioning Service Member: FORMCHECKBOX Yes FORMCHECKBOX No Received VA Services: FORMCHECKBOX Yes FORMCHECKBOX No Eligible Veteran Status: FORMTEXT ?????Disabled Veteran: FORMCHECKBOX Yes FORMCHECKBOX No Date of Actual Military Separation: FORMTEXT ?????Monthly Financial Information FORMTEXT ? FORMCHECKBOX Customer refused to disclose financial information.Personal Income FORMTEXT ? Weekly hours worked: FORMTEXT ?????Gross weekly earnings: $ FORMTEXT ?????Gross Bi-weekly earnings: $ FORMTEXT ?????Hourly wage: $ FORMTEXT ?????Gross monthly earnings: $ FORMTEXT ?????Social Security Retirement (Current maximum amount is $3538 per month): $ FORMTEXT ????? Child support: $ FORMTEXT ?????Interest, dividends, trusts and royalties: $ FORMTEXT ?????Savings (enter monthly amount used from savings): $ FORMTEXT ?????Rental income: $ FORMTEXT ????? Pension or annuities: $ FORMTEXT ?????Other customer income (income not included in categories above): $ FORMTEXT ????? Public Support FORMTEXT ? Pell Gant Recipient: FORMCHECKBOX Yes FORMCHECKBOX NoSSDI income (current maximum amount is $3148 per month): $ FORMTEXT ????? SSDI Amount Reduced for Overpayment or Earnings of $0: FORMCHECKBOX Yes FORMCHECKBOX NoSSI Disabled/Blind/Aged (Current Maximum Amount is $794 per Month): $ FORMTEXT ?????SSDI/SSI Recipient: FORMCHECKBOX Yes FORMCHECKBOX NoSSI Amount Reduced Due to Earnings: FORMCHECKBOX Yes FORMCHECKBOX NoSSI Reduced for 1619b (value must be $0): FORMCHECKBOX Yes FORMCHECKBOX NoSSI for Couples (current maximum amount is $1191 per month): $ FORMTEXT ?????SSI In-Kind Support and Maintenance (current maximum amount is $529.34 per month): $ FORMTEXT ?????SSI or SSDI Eligible based on Disability Determination: FORMCHECKBOX Yes FORMCHECKBOX NoTANF: $ FORMTEXT ?????Exhausting TANF within two-years: FORMCHECKBOX Yes FORMCHECKBOX NoGeneral Assistance (Include payments from State or Local government): $ FORMTEXT ?????Workers’ Comp: FORMTEXT ?????Unemployment Compensation: $ FORMTEXT ?????Veterans' Disability Benefit: $ FORMTEXT ?????Other Public Support "cash benefit" not listed: $ FORMTEXT ?????Non-cash support: $ FORMTEXT ?????Support from Family and Friends FORMTEXT ? Family and Friends Net Earnings (spouse/parent/guardian/children/friend including income, wages or public support or other sources): $ FORMTEXT ?????Any In-Kind Non-Cash Support from Family and Friends: FORMCHECKBOX Yes FORMCHECKBOX NoSupport from Other Sources FORMTEXT ? Private Disability Insurance / Charities: $ FORMTEXT ?????Any In-Kind or non-cash support from a charity: FORMCHECKBOX Yes FORMCHECKBOX NoAdjustments to Income FORMTEXT ? Mortgage/Rent: $ FORMTEXT ?????Other Expenses (include medical or court related) $ FORMTEXT ?????Government garnishment: $ FORMTEXT ?????Child Support garnishment: $ FORMTEXT ?????Allowances FORMTEXT ? Number of Dependents (number of individuals who are dependent upon the customer's and/or family's income and liquid assets.): FORMTEXT ?????Economic Resources FORMTEXT ? Total Savings and Liquid Assets (includes savings, stocks, bonds etc. of the customer, spouse, and parent, if dependent): $ FORMTEXT ?????Reason for Update: FORMTEXT ?????Information Request FORMTEXT ? Source name 1: FORMTEXT ?????From date: FORMTEXT ?????To date: FORMTEXT ?????Address: FORMTEXT ?????ZIP: FORMTEXT ?????State: FORMTEXT ??City: FORMTEXT ?????County: FORMTEXT ?????Telephone number 1: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 2: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 3: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 4: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Comments: FORMTEXT ?????Source name 2: FORMTEXT ?????From date: FORMTEXT ?????To date: FORMTEXT ?????Address: FORMTEXT ?????ZIP: FORMTEXT ?????State: FORMTEXT ??City: FORMTEXT ?????County: FORMTEXT ?????Telephone number 1: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 2: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 3: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 4: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Comments: FORMTEXT ?????Source name 3: FORMTEXT ?????From date: FORMTEXT ?????To date: FORMTEXT ?????Address: FORMTEXT ?????ZIP: FORMTEXT ?????State: FORMTEXT ??City: FORMTEXT ?????County: FORMTEXT ?????Telephone number 1: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 2: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 3: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Telephone number 4: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ?????Type: FORMTEXT ?????Comments: FORMTEXT ?????Work History Information FORMTEXT ?Has the customer ever been employed? FORMCHECKBOX Yes FORMCHECKBOX No If no, proceed to next section.Employer name 1: FORMTEXT ?????Hire date (month and year): FORMTEXT ?????Occupation: FORMTEXT ?????Termination date (month and year): FORMTEXT ?????Is this a Trial Work experience? FORMCHECKBOX Yes FORMCHECKBOX NoTrial Work type: FORMTEXT ?????Is Trial Work a success? FORMCHECKBOX Yes FORMCHECKBOX NoReason for leaving: FORMTEXT ?????Employer address: FORMTEXT ?????ZIP: FORMTEXT ?????State: FORMTEXT ??City: FORMTEXT ?????County: FORMTEXT ?????Telephone number: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ????? Type: FORMTEXT ?????Employer name 2: FORMTEXT ?????Hire date (month and year): FORMTEXT ?????Occupation: FORMTEXT ?????Termination date (month and year): FORMTEXT ?????Is this a Trial Work experience? FORMCHECKBOX Yes FORMCHECKBOX NoTrial Work type: FORMTEXT ?????Is Trial Work a success? FORMCHECKBOX Yes FORMCHECKBOX NoReason for leaving: FORMTEXT ?????Employer address: FORMTEXT ?????ZIP: FORMTEXT ?????State: FORMTEXT ??City: FORMTEXT ?????County: FORMTEXT ?????Telephone number: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ????? Type: FORMTEXT ?????Employer name 3: FORMTEXT ?????Hire date (month and year): FORMTEXT ?????Occupation: FORMTEXT ?????Termination date (month and year): FORMTEXT ?????Is this a Trial Work experience? FORMCHECKBOX Yes FORMCHECKBOX NoTrial Work type: FORMTEXT ?????Is Trial Work a success? FORMCHECKBOX Yes FORMCHECKBOX NoReason for leaving: FORMTEXT ?????Employer address: FORMTEXT ?????ZIP: FORMTEXT ?????State: FORMTEXT ??City: FORMTEXT ?????County: FORMTEXT ?????Telephone number: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ????? Type: FORMTEXT ?????Current Employment Information (complete only if employed at time of application) FORMTEXT ?Job title: FORMTEXT ?????Earning type: FORMCHECKBOX Weekly FORMCHECKBOX Hourly FORMCHECKBOX Bi-weeklyWeekly hours worked: FORMTEXT ?????Gross weekly, hourly, or bi-weekly earnings: FORMTEXT ?????Hire date (month, day, and year): FORMTEXT ?????Employment end date: FORMTEXT ?????Is this Federal Employment: FORMCHECKBOX Yes FORMCHECKBOX NoEmployer name: FORMTEXT ?????Employer address: FORMTEXT ?????ZIP: FORMTEXT ?????State: FORMTEXT ??City: FORMTEXT ?????County: FORMTEXT ?????Telephone number: ( FORMTEXT ??? ) FORMTEXT ????? Ext: FORMTEXT ????? Type: FORMTEXT ?????Employer additional information or comments: FORMTEXT ?????Information source: FORMTEXT ?????Employer contact okay? FORMCHECKBOX Yes FORMCHECKBOX NoEmployed with no earnings? FORMCHECKBOX Yes FORMCHECKBOX NoEmployment Status Case Note (Not Working) FORMTEXT ?Have you ever worked? FORMCHECKBOX Yes FORMCHECKBOX NoHas or will your disability interfere with your ability to get a job? FORMCHECKBOX Yes FORMCHECKBOX NoHave you lost a job due to your disability? FORMCHECKBOX Yes FORMCHECKBOX NoHas or will your disability interfere with training or preparation for a job? FORMCHECKBOX Yes FORMCHECKBOX NoHas or will your disability cause you to need special assistance to perform job duties? FORMCHECKBOX Yes FORMCHECKBOX NoWhat services do you need from TWC-VRS? FORMTEXT ?????Comments: FORMTEXT ?????Employment Status Case Note (Working) FORMTEXT ?Are you in danger of losing your job because your disability prevents the performance of essential job functions? FORMCHECKBOX Yes FORMCHECKBOX NoDo you need services, special assistance, or accommodations to keep your job? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think your current job is below your abilities? FORMCHECKBOX Yes FORMCHECKBOX NoWhat services do you need from TWC-VRS? FORMTEXT ?????Comments: FORMTEXT ?????Application Statement FORMTEXT ?I, the applicant, confirm that I:understand that I am applying for vocational rehabilitation services leading to an employment outcome; FORMTEXT ?understand that Texas law requires that all financial information I provide to the VR must be complete and accurate; FORMTEXT ?agree to participate in all evaluations that are necessary to determine my eligibility for services; FORMTEXT ?have received copies of the program brochures that include information about VR application process, appeals process, mediation procedures, and the availability of the Client Assistance Program; and FORMTEXT ?understand that VR has the right to pursue reimbursement for services purchased for me if I receive a judgment or insurance settlement as a result of a lawsuit, claim, or other legal action related to my disability. FORMTEXT ?Signatures FORMTEXT ?Applicant’s signature:X FORMTEXT ????? Applicant’s name: FORMTEXT ????? Date: FORMTEXT ?????Parent’s, guardian’s, and/or representative’s signature (if applicable):X FORMTEXT ????? Parent’s, guardian’s, and/or representative’s name (if applicable): FORMTEXT ????? Date: FORMTEXT ?????VR representative’s signature:X FORMTEXT ?????VR representative’s name: FORMTEXT ?????Date: FORMTEXT ?????Witness’s signature (if one of the above signs with mark):X FORMTEXT ?????Witness’s name (if one of the above signs with a mark): FORMTEXT ?????Date: FORMTEXT ????? ................
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