What services are you seeking from ACCES-VR?
Are you disabled because of a work-related injury?
Do you use any assistive devices or aids?
Do you have a NYS driver’s license?
Do you have a driver’s license from a state other than New York?
Do you have Access to a motor vehicle?
Do you use public transportation?
Are you able to leave your home?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Are you a veteran?
Yes No
Are you a citizen of the United States?
Yes No
If no, are you legally permitted to work in
this country? Yes No
Check the benefits you now receive:
SSI SSDI Workers Compensation
Other, specify ______________
Do you regularly see a doctor or clinic about your disability? Yes No If yes, indicate date of last visit: ___________
Please provide the name and address of doctor(s) and clinic(s):
(1) (2)
List the highest grade you have successfully completed: ___________
and check the applicable box(es)
GED or High School
Equivalency Diploma Yes No ___
College ____Graduate School
___Doctorate
Special Education
Yes No Do you now attend high school? Yes
No Indicate college degree(s) earned:
Name and address of school you last attended: Name of School Address
List below other people in your household
Full Name Age Their Relationship to You
List below the people ACCES-VR can contact if we are unable to reach you using the information on page 1.
Name Address Phone
List below your work history (include attachments for additional Jobs, if necessary)
Employer Name and Address Dates Employed
From - To
Weekly
Earnings
Job Title and Duties, and
Reason for Leaving
Persons applying foro r receiving rehabilitation services have the right to have any actions or decions of this Office
reviewed. A description of the review process and form can be obtained from any ACCES-VR District Office.
All information will be kept confidential and is subject to verification.
The State Education Department does not discriminate on the basis of age, color, religión, creed, disability, marital status, pregnancy, veteran status,
national origin, race, gender, genetic predisposition or carrier status, or sexualorientation in its recruitment, educational programs, services, and activities.
Portions of any publication designed for distribution can be made available in a variety of formats, including Braille, large print or audiotape, upon request.
Inquiries regarding this policy of nondiscrimination should be directed to the Office of Human Resources Management , Room 528 EB, Education Building,
Albany, NY 12234. Request for publications should be made to the Department’s Publications Sales Desk, Room 309, Education Building, Albany, NY
12234.
