Fill - Free fillable Delaware Nation Vocational Rehabilitation Program (Delaware Nation) PDF form

Delaware Nation

Vocational Rehabilitation Program

P.O. Box 546 • Anadarko, OK 73005

Phone: (405) 247-5873 • Fax: (405) 247-2360 • Toll Free: 1 (866) 435-5873

Dear Applicant,

Thank you for your interest in the Delaware Nation Vocational Rehabilitation program (DNVRP).

DNVRP is designed to help individuals with disabilities to become or remain employed in a job

that is compatible with their disability or disabilities. All services must be geared toward this

goal. If you are found eligible you will meet with a Vocational Rehabilitation (VR) counselor to

develop an Individualized Plan for Employment (IPE) outlining your needs and how those will be

addressed in order to help you become employed in an appropriate position.

Please complete the enclosed application as thoroughly as possible. If you have any questions

about the needed information, please contact our ofﬁce or ask your counselor when you come

in for your initial appointment. The more information you include, the quicker we are able to

determine your eligibility and/or the services you might need. Included are several forms. The

Authorization of Release is important if we need to request information from your doctor(s) or

you give us permission to share information with other agencies or people. The General Health

Checklist helps us to learn more about what your conditions are and how they affect your ability

to work. The Documentation of Disability is very helpful. Please have your medical or

psychological health professional to complete this for us, if possible. You will also ﬁnd

information about the Client Assistance Program (CAP}.

Please include all the items included on the Documentation Checklist when you return your

application. Please do not date your application until you are ready to submit it.

If you are determined eligible and are involved with any other program that is providing services,

such as through your tribe or through the state's VR program (DRS), please let us know so we

can be sure we are all working together to help you reach your employment goal. In some

instances there are programs that can cover certain things the DNVRP is unable to and we may

be able to help with things they are not able to.

Delaware Nation

Vocational Rehabilitation Program

Required Document Checklist

Applicant must provide at least one form of documentation for each of the following areas Indicated.

DOCUMENTS REQUIRED:

1. ____ PROOF OF INCOME (Include all Income for all household members)

A. Social Security Award Letter or VA Award Letter

B. Copy of beneﬁts check(s)

C. Income veriﬁcation from the Department of Human Services (OHS) or a letter stating

what services you are receiving

D. Wages (either #1 or #2)

1. Letter from employer

a. Must be on letterhead stationary or notarized

b. Must Include dates of employment, average hours worked per week

and gross wages for the month

2. Copy of most recent check stub

2. ____ PROOF OF TRIBAL ENROLLMENT

A. CDIB Card with roll number & which tribe you are enrolled in

B. Tribal membership card

C. Census card or letter from your tribe or BIA proving enrollment or Indian Preference

for hiring purposes

3. ____ PROOF OF AGE

A. CDIB

B. Tribal membership card

C. Driver's license or state-Issued ID

D. Military-issued ID

4. ____ PROOF OF SOCIAL SECURITY NUMBER

A. Social Security card

B. Letter or document from the Social Security Administration stating your social

security number

C.Tribal enrollment veriﬁcation with your social security number included

D. Military-Issued ID with your social security number included

5.

____ PROOF OF MAILING ADDRESS/RESIDENTIAL VERIFICATION

A. Utility bill in your name. This can be gas or electric, but not phone, cell phone,

Internet or cable

B. Driver's license or state-Issued ID with your current address

C. Rent receipt or lease In your name including your current address

D. Voter's registration card

E. Completed DNVRP residence form showing who you live with as well as one of the

above In their name

Delaware Nation

Vocational Rehabilitation Program

Required Document Checklist

6. ____ PROOF OF DISABILITY

A. Doctor's or other relevant professional's statement (verifying disability and limitations)

within the last year

8. School Assessment records

C. Copy of SSDI check, Aid to Disabled check, VA Disability check or SSI check (please

note that additional details will likely be needed to show that you can work with help

from VR services)

D. Completed DNVRP Documentation of Disability form from the appropriate

professional

Delaware Nation

Vocational Rehabilitation Program

P.O. Box 546 • Anadarko, OK 73005

Phone: (405) 247-5873 • Fax: (405) 247-2360 • Toll Free: 1 (866) 435-5873

APPLICATION FOR SERVICES

1. I am applying for services from the Delaware Nation Vocational Rehabilitation Program

(DNVRP).

I understand that in order to receive Vocational Rehabilitation (VR) services, I must have:

a. A physical or mental disability which interferes with my ﬁnding a job, and

b. A reasonable chance to be able to work after I receive VR services.

I understand that in applying for services, I am entitled to an evaluation of my eligibility

for services.

2. If I am found eligible, I understand that my counselor will involve me in the development of

my VR plan and my program will be reviewed at least once a year. Similar beneﬁts and

referral to other agencies will also be used to assist me in meeting my VR plan. I understand

that I must keep scheduled appointments.

3. I understand that VR services are dependent upon the availability of openings at the DNVRP

and upon availability of funds and openings with the state agency for rehabilitation assistance.

4. I am aware that I have the right to appeal decisions made by the DNVRP staff by requesting

a meeting with the Program Coordinator verbally or in writing within 3days of the of the

effective date of the decision. I also understand that I may continue to appeal any grievance

beyond the Program Coordinator's level provided that I make this request within 30 days of

the Program Coordinator's decision.

5. I understand that all information will be treated in a conﬁdential manner.

TH1S FORM HAS BEEN REVIEWED WITH ME AND I HAVE BEEN GIVEN A COPY.

________________________________________ _____________________

Applicant's Signature Date

(Parent or guardian, if applicable)

Delaware Nation

Vocational Rehabilitation Program

Consumer Information

Name: ___________________________________________________________________

(Last) (First) (Middle)

Social Security Number: _______________________________________________

!

Telephone Number: ( _) _________________ ( _) _________________

(Home) (Alternate)!

E-mail: ______________________________________________________________

Date Of Birth: __________________________ Sex: Male Female

Marital Status: Married Never Married Widowed Divorced

!

Separated

Indian Tribe: _________________________ CDIB: Yes No

Total Number of Family In The Home: ___________

Address: ___________________________________________________________________

City: _________________________________ State: _______ Zip: __________________

Finding directions: ___________________________________________________________

Guardian Name: ____________________________________________________________

(If Applicable) (Last) (First) (Middle)

!

WHAT IS YOUR DISABILITY AND HOW DOES IT LIMIT YOUR ABILITY TO WORK?

____________________________________________________________________________

HAVE YOU BEEN SEEN BY A DOCTOR FOR PROBLEMS RESULTING FROM YOUR

DISABILITY? Yes No

If yes, please list:

____________________________________________________________________________

Doctor’s Name and Address Doctor’s Telephone Number

!

____________________________________________________________________________

Dates seen by Doctor Reason Seen

____________________________________________________________________________

Doctor’s Name and Address Doctor’s Telephone Number

!

____________________________________________________________________________

Dates seen by Doctor Reason Seen

____________________________________________________________________________

Doctor’s Name and Address Doctor’s Telephone Number

!

____________________________________________________________________________

Dates seen by Doctor Reason Seen

DO YOU HAVE PRIVATE MEDICAL/HOSPITAL INSURANCE, MEDICARE AND/OR MEDICAID?

!

YES List type, company name, address, and policy/group or case number:

____________________________________________________________________

NO List reason: __________________________________________________________

ARE YOU A VETERAN? YES NO

If yes, list serial number and dates of service: _____________________________________

!

DO YOU HAVE A SERVICE CONNECTED DISABILITY? YES NO!

If yes, specify: _____________________________________________________________

SSI/SSDI STATUS

SSI Status: _________ SSDI Status: _________

!

(O = Not an Applicant, I = Applicant Allowed Benefits, 2 = Applicant Denied Benefits,3 = Status of

Application Pending, 4 = Not Known If Applicant, 5 = Benefits Discontinued Prior to Application)

EDUCATION!

!

Highest Grade Completed: __________ Special Education Student: Yes No

WORK STATUS

Current Work Status: Employed Currently Unemployed

Hours Worked Week Prior to Application: _______ Earnings Week Prior to Application:$ ________

DO YOU HAVE MEDICAL/HOSPITAL INSURANCE THROUGH YOUR EMPLOYER?

YES List type, company name, address, and policy/group or case number:

___________________________________________________________________

NO List reason: ____________________________________________________

!

HOW WERE YOU REFERRED TO OUR OFFICE? ______________________________________

LIST MEMBERS OF YOUR IMMEDIATE HOUSEHOLD WITH EMPLOYMENT AND INCOME

INFORMATION:

Name Relationship Employer Weekly Hours Weekly Net Salary

____________________________________________________________________________

LIST ANY OTHER INCOME (SSI, SSDI, Social Security, Public Assistance, Worker's Comp. etc.)

Source Amount Case Number Time Received

____________________________________________________________________________

HAVE YOU EVER APPLIED FOR REHABILITATIVE OR VISUAL SERVICES?

!

YES If so, when? ____________________ NO

HAVE YOU EVER DEFAULTED ON A STUDENT LOAN? YES NO

LIST YOUR EDUCATION HISTORY:

HIGH SCHOOL:

____________________________________________________________________________

Name of School Address City/State

____________________________________________________________________________

Grade/Hours Completed Dates

COLLEGE:

____________________________________________________________________________

Name of College/University Address City/State

____________________________________________________________________________

Grade/Hours Completed Major Dates

TECHNICAL:

____________________________________________________________________________

Name of Institution Address City/State

____________________________________________________________________________

Grade/Hours Completed Major Dates

OTHER:

____________________________________________________________________________

Name of Institution Address City/State

____________________________________________________________________________

Grade/Hours Completed Major Dates

LIST YOUR LAST THREE JOBS:

____________________________________________________________________________

Employer Address City/State

____________________________________________________________________________

Dates Employed # of HRS/WK Reason for Leaving

____________________________________________________________________________

Employer Address City/State

____________________________________________________________________________

Dates Employed # of HRS/WK Reason for Leaving

____________________________________________________________________________

Employer Address City/State

____________________________________________________________________________

Dates Employed # of HRS/WK Reason for Leaving

LIST THREE PEOPLE WHO WILL ALWAYS KNOW HOW TO LOCATE YOU:

(1) Name: __________________________________ Relationship ____________________

Address: _________________________________________________________________

Street or Rte # City State ZIP

Telephone: _____________________ E-mail: _________________________________

(2) Name: __________________________________ Relationship ____________________

Address: _________________________________________________________________

Street or Rte # City State ZIP

Telephone: _____________________ E-mail: _________________________________

(3) Name: __________________________________ Relationship ____________________

Address: _________________________________________________________________

Street or Rte # City State ZIP

Telephone: _____________________ E-mail: _________________________________

Do you participate in Native American Indian Ceremonial Activities? If so, what?

____________________________________________________________________________

This is conﬁdential information and no penalty will be inﬂicted for your answers.

WHAT SERVICES DO YOU NEED? (Use additional pages or back of page, if necessary.)

____________________________________________________________________________

Delaware Nation

Vocational Rehabilitation Program

AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)

I. INDIVIDUAL INFORMATION (FOR PERSON WHOSE INFORMATION Will BE SHARED)

____________________________________________________________________________

Name Date of Birth!

____________________________________________________________________________

Address City!

____________________________________________________________________________

State ZIP Area Code & Telephone Number

II. SCOPE & PURPOSE FOR SHARING INFORMATION

I understand protected health information Is Information that Identiﬁes me. The purpose of this

authorization Is to allow ________________________________________________________

to share my protected health Information.

llI. AUTHORIZATION & INFORMATION TO BE SHARED

I authorize ____________________________ as set forth below, to share my protected health

information for reasons In addition to those already permitted by law.

A. Persons/Organizations receiving Information and purpose for sharing

____________________________________________________________________________

Name, Address, Phone & Fax, Patient ID # (if applicable) Relationship

If this box is checked, I authorize the Delaware Nation Vocational Rehabilitation Program to

share my PHI with the Delaware Nation Executive Committee, as needed, for complaint

investigation and And administration of the program. I understand this authorization is optional,

and other steps must be taken to resolve a complaint prior to the Executive Committee’s

involvement. Further, I understand sharing of information with the Executive Committee may

include information about my disability services requested or received and other personal

information information included in my case ﬁle.

______________ _________________

Initials Date

Delaware Nation

Vocational Rehabilitation Program

AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)

B. Information to be shared

1. Speciﬁc Information to be shared (check one or more boxes below).

Medical Psychological Vocational

Other (specify) __________________________________

2. The purpose and need for such disclosure:

Establish eligibility for rehabilitation services

Develop a vocational plan for client

Determine need for and/or type of treatment

3. The Information I authorize may Include information that could be considered information

about communicable or non communicable which may Include, but not limited to, diseases such

as hepatitis, syphilis, gonorrhea, and the Human Immunodeﬁciency Virus, also known as

Acquired Immune Deﬁciency Syndrome (AIDS) (Statute 63 O.S. 1-502-2[B1). I understand that

information in my records that I have a communicable or non-communicable disease is made

confidential by law and cannot be released without my permission except In limited circumstance

Including release to persons who have had risk of exposures. When such Information Is

released It cannot contain information from which I can be identiﬁed unless release of that

Identifying Information Is authorized by me, by an ofﬁcer of the court or the Department of

Health by law. I understand that these records may Include psychiatric, alcohol and drug abuse

Information, occupational Information or Information regarding other Insurance coverage.

Delaware Nation

Vocational Rehabilitation Program

AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)

IV. EXPIRATION & REVOCATION

A. This authorization will expire (must choose one):

12 months from the date signed in Part V.

Other (Insert date or event): ______________________

B. Right to revoke

I understand I may change this authorization at any time by submitting a written request

to the Delaware Nation Vocational Rehabilitation Program Coordinator . I understand I

cannot restrict Information that may have already been shared based on this authorization.

V. SIGNATURES

This document must be signed by the Individual's legal representative .

________________________________________________________________________

Signature (Patient or Legal Representative) Date

_________________________________________________________________________

Printed Name (Patient or Legal Representative) Capacity of Legal Representative (If applicable)

Delaware Nation

Vocational Rehabilitation Program

Consumer ID II ______________________ VR Counselor _________________________

DOCUMENTATION OF DISABILITY

Name: __________________________ Date of Birth ___________ SSN#_________________

Dear Doctor :

The above individual has submitted an application for rehabilitation services. In order to assist

the applicant, I am required by Federal law to verify that this individual has a substantial

disability which results in an impediment to employment .

I am mandated by Federal law and Department Policy to determine this individual's eligibility

within sixty (60) days. Therefore, I am asking for your assistance on providing answers to the

following questions:

(1) Diagnosis: Please describe the disabling condition(s) and supply the appropriate diagnosis,

including diagnostic codes (either ICD-9 or DSM-IV codes). _________________________

_________________________________________________________________________

(2) Prognosis: ________________________________________________________________

(3) Recommendation(s) for treatment: Can this individual's condition be improved through treatment?

Yes No Unknown If yes, what type of treatment is recommended?

_________________________________________________________________________

(4) Functional Limitation(s): Please list all limitations and restrictions created by this disability.

_________________________________________________________________________

(5) Recommendations for individual's vocational rehabilitation plan: ______________________

_________________________________________________________________________

Delaware Nation

Vocational Rehabilitation Program

Consumer ID II ______________________ VR Counselor _________________________

DOCUMENTATION OF DISABILITY

Thank you very much for your assistance.

• Physician Signature : ____________________________________ Date: ________________!

Physician Name (Please Print) __________________________________________________

VR Counselor Signature : _________________________________ Date: ________________

!

• A mental health professional may also ﬁll out this form for a psychological disability .

Delaware Nation

Vocational Rehabilitation Program

P.O. Box 546 • Anadarko, OK 73005

Phone: (405) 247-5873 • Fax: (405) 247-2360 • Toll Free: 1 (866) 435-5873

CONSUMER RESPONSIBILITIES

To make the rehabilitation effort a success, a Consumer and V .R. Counselor and/or Job

Developer must work together to reach chosen goals. This shared responsibility requires that

the consumer accept these basic responsibilities:

l. Threats (physical or verbal): DNVRP has a right to refuse and/or terminate services.

2. Keep appointment for medical examinations and other evaluations.

3. Follow the advice of doctors and other licensed treatment professionals.

4. Take an active part in developing the Individualized Plan for Employment (IPE).

5. Attend training classes on regular basis.

6. Take part in regular reviews (at least once a year) of the Individualized Plan for Employment (IPE).

Also take part in any revisions to the program.

7. Maintain satisfactory progress toward completing the rehabilitation program .

8. Keep the V .R. Counselor informed of changes in the consumer's address, ﬁnancial scat us,

or other program related changes.

9. Apply for and use any comparable beneﬁt s and services for which the consumer is eligible

to defray in whole or in part the cost of services in the IPE.

10. Working with the Counselor and/or Job Developer to obtain suitable gainful employment.

________________________________________________ _____________________

Consumer Signature Date

________________________________________________ _____________________

Counselor Signature Date

Delaware Nation

Vocational Rehabilitation Program

GENERAL HEALTH CHECKLIST

NAME ______________________________ SS # ________________ CSLR ______________

DATE OF BIRTH _____________________ HEIGHT ____________ WEIGHT ____________

Please answer "YES" or "NO" to all Items In each row.

If yes, has it

kept you

from working

Yes

No

Yes

No

Do you have …………………………….

1. A disorder of eyes, ears, nose or throat? ………………………….

2. Frequent dizziness, fainting, headaches seizures, convulsions,

paralysis or stroke? …………………………………………………

3. A mental or nervous disorder? ……………………………………..

4. Persistent coughing, bronchitis, asthma, emphysema,

tuberculosis or other disorder of the lungs? ………………………

5. Chest pain, high blood pressure, rheumatic, fever, heart murmur

or other disorder of the heart or blood vessels? ………………….

6. Intestinal bleeding, ulcers, hernia, colitis, other disorder of the

stomach, intestines, liver or gallbladder? ………………………….

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

8. Diabetes, thyroid problems or other endocrine disorders? ……..

9. Arthritis or other disorder of the muscles or bones,

Including the spine, back or joints? ………………………………..

10. Loss of use of arms, legs, or any body part? ……………………

11. Absence or amputation of any body part? ……………………….

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

13. Allergies ……………………………………………………………..

14. Anemia or any other disorder of the blood? …………………….

15. Addiction to or excessive use of alcohol or any habit

forming drugs? ……………………………………………………..

16. Any other physical or mental condition? ...................................

17. If you answered yes to #16, please specify ________________________________________________________

__________________________________________________________________________________________

18. Have you been or are you being treated for any of these conditions? YES

NO

If NO, why not? ________________________________________________________________________

If YES, Condition Who treated you? When?

_______________________ ___________________________ _________________

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

If YES, Condition Where? When?

_______________________ ___________________________ _________________

20. Are you taking any medications? YES NO

If YES, Condition Which medicines?

_______________________ ___________________________

21. Do you have any restrictions from these conditions? YES 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.

____________________________________________________ _______________________

Signature of Applicant Date

Person who provided information, if not applicant: __________________________________________

Comments:

Delaware Nation

Vocational Rehabilitation Program

P.O. Box 546 • Anadarko, OK 73005

Phone: (405) 247-5873 • Fax: (405) 247-2360 • Toll Free: 1 (866) 435-5873

Please observe our ofﬁce schedule:

Mondays, Tuesdays, and Thursdays - Appointment Days

No appointments after 3:00 PM unless authorized by counselor.

Wednesdays - Walk-in Day

For existing cases only. New applicants must turn in their application and await a call

from their counselor to schedule their intake appointment.

ADRIAN----8:00-11:30 & 1:30-4:00 only

Fridays - Administrative Day

Counselors will handle all paperwork necessary to keep your case open and going. You

will not be able to meet or speak with them as they tend to administrative duties.

If you have a general question that doesn't require your counselor, or you just need to

drop something off, please feel free to call or drop by and speak with the Administrative

Assistant/VR Technician.

Thank you,

DNVRP Staff

Client Assistance Program

CAP works with YOU!

Ofﬁce of Disability Concerns

The Ofﬁce of Disability Concerns provides service under the Client Assistance Program (CAP)

serving as a vital link between the Oklahoma Department of Oklahoma Rehabilitation Services

(OKDRS) and the disability community. CAP provides advocacy to persons with disabilities who

are seeking or receiving vocational rehabilitation (VR) services from DRS, as well as individuals

who are receiving services from independent living centers or other Rehabilitation Act funded

programs such as Tribal VR and Higher Education.

CAP is an independent advocate for clients and client applicants.

CAP was established to improve communication and help resolve issues between client and

vocational rehabilitation/DR staff and other Rehabilitation Act funded program staff.

CAP also helps client understand the rehabilitation process and the beneﬁts available under the

Rehabilitation Act of 1973. CAP’s role is to provide information about beneﬁt available under the

Rehabilitation Act and to assist client with understanding their rights and responsibilities in

relation to receipt of these beneﬁts.

Additionally, CAP ensures that clients' rights are protected under the Rehabilitation Act.

Ofﬁce of Disability Concerns

Client Assistance Program

2401 NW 23rd St.

Suite90

Oklahoma City, OK 73107

Toll Free: (800) 522-8224

(405) 522-8224

www.ok.gov/odc/C.A.P./

CAP@odc.state.ok.us

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