OMB Approved No. 2900-0009
Respondent Burden: 15 minutes
Expiration Date: 11/30/2022
APPLICATION FOR VOCATIONAL REHABILITATION FOR CLAIMANTS
WITH SERVICE-CONNECTED DISABILITIES
(Chapter 31, Title 38, U.S.C.)
DO NOT WRITE IN THIS SPACE
(VA DATE STAMP)
PURPOSE OF VOCATIONAL REHABILITATION: Vocational Rehabilitation and Employment provides
services that will assist certain claimants with disabilities in obtaining and maintaining suitable employment.
If employment is not an option because of the severity of the claimants' disability conditions, services to assist
them to achieve maximum independence in their daily living activities may also be provided.
IMPORTANT: To decide if you should fill out this form, please read the information on page 2 of this form.
1. FIRST, MIDDLE, LAST NAME OF CLAIMANT
9. IF YOU ARE MOVING WITHIN THE NEXT 30 DAYS, PROVIDE YOUR NEW ADDRESS BELOW:
I HEREBY CERTIFY THAT the information I have entered on this form is true and complete to the best of my knowledge and belief. I
realize that making willful false statements concerning a material fact in a claim of vocational rehabilitation benefits is a punishable
offense that may result in a fine or imprisonment, or both. (Reference: 38 U.S.C. 3802(a))
11A. SIGNATURE OF CLAIMANT
11B. DATE SIGNED (MM-DD-YYYY)
7. E-MAIL ADDRESS OF CLAIMANT
8. CELL PHONE NUMBER (Include Area Code or write "None" if no available cell phone number.)
5. MAILING ADDRESS (Number and street or rural route, City, State and ZIP Code, OR write "None," if no mailing address)
4. DATE OF BIRTH (MM-DD-YYYY)
3. VA FILE NUMBER (If different from Item 2)
2. SOCIAL SECURITY NUMBER
10. NUMBER OF YEARS OF EDUCATION
PAGE 1
SUPERSEDES VA FORM 28-1900, SEP 2014,
WHICH WILL NOT BE USED.
VA FORM
NOV 2019
28-1900
6. MAIN TELEPHONE NUMBER (Include Area Code, or write "None" if no available telephone number)
click to sign
signature
click to edit
INSTRUCTIONS FOR APPLYING FOR VOCATIONAL REHABILITATION SERVICES
TO APPLY OR RECEIVE INFORMATION AND ASSISTANCE:
To apply, you may submit the completed application to the nearest VA office or apply online at www.va.gov.
• You may obtain information and assistance from any VBA office or online at http://www.vba.va.gov/bln/vre/index.htm.
• Local representative of claimant's service organizations and the American Red Cross also have information and forms available.
EVALUATION: A combined and compensable service-connected disability rating of 10 percent or more by VA is required for you to apply for
vocational rehabilitation services. Once your application is received, we will provide you a comprehensive evaluation, where a VA Vocational
Rehabilitation Counselor (VRC) will work with you to determine:
1. If you meet the requirements for entitlement Chapter 31 benefits.
2. If you are within the time limit for receiving this benefit, which is generally 12 years from the date VA notified you of your compensation rating
for at least a 10% service-connected disability.
PLANNING AND COUNSELING: After a VRC determines that you meet the entitlement requirements, your assigned VRC will assess your
vocational rehabilitation and employment needs with you. Subsequently, your VRC will develop a plan of services and assistance with you to help
you reach your employment goal. Counseling will be available throughout your program to help you when problems arise.
REHABILITATION SERVICES: Vocational rehabilitation programs do not always require training. You may only need employment services to help
you get a suitable job. If your VRC determines that you need training to reach your vocational goal, he or she will also determine the number of
months needed to complete your training. You may train in a vocational school, a specialized rehabilitation facility, an apprenticeship program,
other on-job training position, a college, or a university.
If training is necessary, VA will provide medical and dental care treatment, assistance to get and keep suitable employment, and other services
you may need. If employment is not currently feasible for you, VA may provide services and assistance to improve your ability to live
independently.
SUPPORT: VA may pay for tuition, fees, books, equipment, tools, or other supplies you need to succeed in your rehabilitation program. During
your training, you may qualify for a monthly subsistence allowance to help you with your living expenses. Payment for subsistence allowance
depends on your type of training, rate of attendance, and number of dependents. You will receive this allowance in addition to any VA
compensation or military retired pay that you may be receiving.
PRIVACY ACT: The 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. VA needs the information this form requests to help determine your
eligibility to the benefit) 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 response is required to obtain benefits (5 CFR 1320.8(b)(3)(iv)). Giving us
your Social Security Number (SSN) information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). The
VA will not deny benefits for any individual 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.
RESPONDENT BURDEN: We need this information in order for claimants with compensable service-connected disabilities to apply for vocational
rehabilitation under title 38, U.S.C. chapter 31. We estimate that you will need an average of 15 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 www.reginfo.gov/public/do/PRAMain.
PAGE 2
• Mailing Address: You will not be denied benefits on the basis that you do not have a mailing address under the provisions of 38 U.S.C. 5126. If
you do not have a mailing address, please write “none” in response to question 5. However, you must provide an alternative means of contact
if you are unable to provide an address or telephone number, so we can schedule your initial evaluation appointment.
VA FORM 28-1900, NOV 2019