OMB Control No. 2900-0092
Respondent Burden: 45 Minutes
Expiration Date: 08-31-2018
VA FORM
SEP 2015
28-1902w
REHABILITATION NEEDS INVENTORY (RNI)
Respondent Burden: We need this information for educational and vocational planning to help you make the best use of your vocational rehabilitation benefits.
Title 38, United States Code chapter 31, allows us to ask for this information. We estimate that you will need an average of 45 minutes to review the instructions, find
the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., to determine entitlement to vocational rehabilitation benefits and to plan a program of rehabilitation
services) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. Your obligation to respond is voluntary. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself
will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a
Federal Statute of law in effect prior to January 1, 1975, and still in effect. Information submitted is subject to verification through computer matching programs with
other agencies.
1. NAME
(First, middle, last)
3. CURRENT ADDRESS
2. TELEPHONE NUMBER(S)
7. CLAIM NUMBER
4a. E-MAIL ADDRESS 1
HOME PHONE NUMBER CELL PHONE NUMBER
8. SOCIAL SECURITY NUMBER
12. HOW DO YOU EXPECT THIS PROGRAM TO HELP YOU?
13. WHAT ARE THE JOBS OR CAREER FIELDS YOU ARE MOST INTERESTED IN?
14A. HAVE YOU EVER PARTICIPATED
IN A PROGRAM OF VOCATIONAL
REHABILITATION BEFORE?
14B. CHECK ALL THAT APPLY IN WHICH YOU HAVE PARTICIPATED
YES
(If "Yes," complete Items 14B and 14C)
NO
A
B
STATUS
AVERAGE GROSS
MONTHLY SALARY
DESCRIBE JOB DUTIES IN DETAIL
OTHER (Please explain)
VA VOCATIONAL REHABILITATION
STATE VOCATIONAL REHABILITATION
PRIVATEWORKER'S COMP
14C. LIST ANY TYPE OF SERVICES YOU WERE PROVIDED
(i.e., training, medical, vocational testing, functional capacities, job search activities):
JOB TITLE
COMPANY NAME
PERMANENT POSITION
TEMPORARY ASSIGNMENT OR CONTRACT
REASON FOR LEAVING
DATES
FROM TO
FULL TIME
PART TIME
AVERAGE GROSS
MONTHLY SALARY
JOB TITLE
15. CIVILIAN EMPLOYMENT HISTORY: Please start with your most current position.
COMPANY NAME
PERMANENT POSITION
TEMPORARY ASSIGNMENT OR CONTRACT
DATES
FROM TO
STATUS
FULL TIME
PART TIME
EMPLOYMENT
Please fill out each area as completely as possible. If you have a resume, please attach it.
SUPERSEDES VA FORM 28-1902w, FEB 2012,
WHICH WILL NOT BE USED
NO
YES NO
YES
WORK PHONE NUMBER
6. MARITAL STATUS
5. GENDER
MALE
FEMALE
4b. E-MAIL ADDRESS 2
9. CLAIMING DEPENDENTS?
#
10. NICKNAME/AKA 11. EMERGENCY CONTACT INFORMATION
CONTACT NAME
CONTACT PHONE NUMBER CONTACT RELATIONSHIP
14. HAVE YOU EVER PARTICIPATED IN OR ARE CURRENTLY PARTICIPATING IN A VA EDUCATION BENEFIT PROGRAM?
