Fillable VOCATIONAL REHABILITATION (VR) SERVICES APPLICATION (California)

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VOCATIONAL REHABILITATION (VR) SERVICES APPLICATION (California)

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STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION
VOCATIONAL REHABILITATION (VR) SERVICES APPLICATION
DR222 (REGS/Rev. 05/20) Page 1 of 2
Privacy Statement: The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy
Act (5 USC 552a(e)(3)) require this notice to be provided to individuals when collecting personal information. The
information requested on this form, including the Social Security Number, is necessary to properly identify the
individual to ensure that the Department provides services to the correct individual. Failure to provide the information
requested may result in delays in services. Department authority: Welfare & Institutions Code Sec. 19005, 19005.1,
19010.
Last Name
Other Name(s) Used
First Name
Middle Initial
Street Address
City
Zip Code
Mailing Address (If Different from above)
Phone Number
Social Security Number
XXX-XX-XXXX
Date of Birth
Age
Cell Phone Number
Email Address
Please describe your physical or mental impairment that constitutes or results in substantial impediment to
employment
How can we help you?
Who referred you?
Full name of person not in your home who will always know where you live:
Relationship
Street Address
City
Phone Number
RELEASE OF INFORMATION TO PROSPECTIVE
EMPLOYERS:
I hereby authorize the Department of Rehabilitation to
release information (except medical and psychological)
to prospective employers for the purpose of assisting me
in job placement. I understand that only information
necessary to assist me in job placement will be released.
This consent applies until such time as my case is closed
or I specifically withdraw my consent.
ORIENTATION MATERIALS:
I have received and read my “Consumer Information
Handbook and have discussed with my Counselor the
following concepts: Civil Rights, Eligibility
Requirements, Informed Choice, Employment Outcome
& Professional Development, Scope of Services,
Confidentiality, Appeals Procedures, and the Client
Assistance Program (CAP).
Initials: ________ (Counselor) ________ (Consumer)
Yes
No
STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION
VOCATIONAL REHABILITATION (VR) SERVICES APPLICATION
DR222 (REGS/Rev. 05/20) Page 2 of 2
The Immigration Reform and Control Act of 1986 states employees should only hire American citizens and aliens
who are authorized to work in the United States. To verify your employment eligibility, please check a box below.
This does not replace requirements of employers as specified under the Immigration Reform and Control Act of 1986.
I am:
1.
A citizen or national of the United States
2.
An alien lawfully admitted for permanent residence (Alien Number A ________ ).
3.
An alien authorized by the Immigration and Naturalization Service to work in the United
States (Alien Number A ________ or Admission Number ________, expiration of
employment authorization, if any ________ ).
4.
None of the above.
SEE ATTACHMENT FOR YOUR APPEAL RIGHTS INFORMATION AND HOW TO CONTACT YOUR CAP ADVOCATE.
Applicant’s Signature
Date Signed
Parent/Guardian’s Signature (required for minor)
TO BE COMPLETED BY COUNSELOR
Counselor’s Signature
Date Signed
Counselor’s Name (Printed)
Counselor’s Phone
Distribution:
Case Folder
Applicant
STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION
YOUR RIGHTS AND REMEDIES
DR1000 (Rev. 10/13) Page 1 of 2
If questions or issues arise while you are an applicant or a consumer of the Department
of Rehabilitation (DOR), talk with your Rehabilitation Counselor. You may also request
an informal meeting with your Rehabilitation Counselor’s Team Manager.
You have the right to request an administrative review with the District Administrator.
You may also seek, as set forth below, an administrative review concurrently with a
formal request for mediation and/or fair hearing. However, most problems can be
resolved informally and more quickly at the district level. You may bring a family member,
other representative, or advocate with you any time you meet with the DOR staff.
CLIENT ASSISTANCE PROGRAM. To seek an advocate or for information regarding
vocational rehabilitation services or the appeal process, the Client Assistance Program
(CAP) administered by Disability Rights California may be available to assist you.
Information is available at the Disability Rights California website
(http://www.disabilityrightsca.org), by phone at 800-776-5746 or 800-719-5798
TTY/TDD (Telecommunication Device for the Deaf and Hard of Hearing), or at the DOR
website (http://www.dor.ca.gov).
You have the right to take any of the following steps should issues arise:
REHABILITATION COUNSELOR. Most misunderstandings and issues can be resolved
by talking them over with your Rehabilitation Counselor. It is your responsibility to let
your Rehabilitation Counselor know there is an issue.
TEAM MANAGER. If you believe that you and your Rehabilitation Counselor cannot
resolve the issue, you may request an informal meeting with the Team Manager to
discuss the issue.
ADMINISTRATIVE REVIEW. You may request an administrative review by the District
Administrator within one year of the action or decision. An administrative review decision
will be rendered within 15 calendar days of the date of your request, unless you agree
to a later date. If you disagree with an administrative review decision, you may file a
request for fair hearing within 30 calendar days of the receipt of the written decision of
your administrative review.
MEDIATION. Mediation is another option for resolving disputes with the DOR. You may
file a request for confidential mediation within one year of the DOR action or decision
with which you disagree. A qualified, impartial mediator can help you find solutions that
are satisfactory to you and the DOR. If the DOR agrees to mediate, the mediation will
be held within 25 calendar days from receipt of the request, unless you agree to a later
date. A written request for mediation and/or fair hearing may be filed concurrently.
FAIR HEARING. If you are dissatisfied with any action or decision of the DOR relating
to your application or receipt of vocational rehabilitation services, you may file a request
for a fair hearing within one year of the DOR action or decision or within 30 calendars
STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION
YOUR RIGHTS AND REMEDIES
DR1000 (Rev. 10/13) Page 2 of 2
days of the receipt of written decision of your administrative review (see above). A fair
hearing will be held within 60 calendar days of the receipt of your written request, unless
you agree to a later date. At the hearing, you may appear in person, and may be
accompanied by a representative or advocate of your choice. It may be to your benefit
to first work through the administrative review process or mediation (see above) before
requesting a fair hearing. If you are not satisfied with the fair hearing decision, you may
file a Writ of Mandate with the California Superior Court within six months of the decision.
To request a mediation and/or fair hearing, please obtain form DR 107 Request for
Mediation and/or Fair Hearing from one of the following options: contact the DOR
Mediation and Fair Hearing Office by phone at 916-558-5860 or by email at DOR
Appeals Info (appealsinfo@dor.ca.gov); visit the DOR website (http://www.dor.ca.gov);
or contact a CAP advocate (see CAP contact information above).
DISCRIMINATION. If you believe that the DOR or its contractor or grantee has unlawfully
discriminated against you because of one or more of the following protected categories,
your race, color, religion, ancestry, physical or mental disability, national origin, medical
condition, genetic information, sexual orientation, marital status, age, gender, gender
identity, gender expression, military status, or veteran status or retaliation, you have the
right to pursue the following options: 1) Make an oral or written request for an
administrative review to the District Administrator, who oversees the office where your
case is assigned. The request should include: your name, address, and phone number;
the name and title of the person against whom the complaint is being made; a description
of the alleged discrimination; the protected category; and the remedy being sought. 2)
File a discrimination complaint directly with DOR’s Office of Civil Rights (OCR). For more
information or to obtain a discrimination complaint form contact the DOR’s OCR directly
by phone at 916-558-5850.
3) File a complaint with the U.S. Department of Education’s Office for Civil Rights. For
more information contact the U.S. Department of Education’s Office for Civil Rights
directly by telephone at 800-421-3481.
Requests for administrative review and complaints of discrimination must be made within
180 days of the date of alleged discrimination.
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Completed 30 May 2021

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