EMPLOYMENT PLANNING APPLICATION

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The Pennsylvania Office of Vocational Rehabilitation (OVR) helps individuals with disabilities prepare for, obtain, or keep suitable employment. TO BE ELIGIBLE FOR OVR SERVICES, YOU MUST: 1. Have a disability that causes a substantial impediment to employment 2. Need services from OVR to achieve employment, and 3. Be able to benefit from services in terms of an employment outcome. CONFIDENTIALITY All medical and personal information shall be held as confidential. Use of such information will be limited to purposes directly connected with your rehabilitation program.

*Indicates required field – Please complete each question to the best of your knowledge and ability.

Italicized sections with a double border will be completed by OVR Counselor.

By returning completed application to OVR, customer acknowledges they would like to be contacted by an OVR representative.

PERSONAL DATA
APPLICATION DATE:	*FIRST NAME	MI	*LAST NAME
MAIDEN NAME/OTHER NAME(S) UNDER WHICH RECORDS MAY BE LISTED	SSN	AGE
*DATE OF BIRTH	*CITIZEN STATUS US Citizen Refugee Non-US Citizen Permanent Alien Illegal Alien Unknown Temporary Alien	*ARE YOU LEGAL TO WORK IN THE U.S.? Yes No Don’t Know
*ETHNICITY Hispanic/Latino Non-Hispanic/Latino Do not wish to disclose	*RACE American Indian or Alaskan Hawaiian Native/Other Native Pacific Islander Asian White Black/African American Do not wish to disclose	*GENDER Male Female Does not wish to self-identify
*ARE YOU A VETERAN? Yes No ARE YOU THE SPOUSE OF A VETERAN? Yes No	*IF YES, SERVICE CONNECTED DISABILITY? Yes No *IF YES, PERCENTAGE OF DISABILITY:	*VETERAN’S ADMINISTRATION (VA) VOCATIONAL REHABILITATION AND EMPLOYMENT SERVICES ELIGIBLE? Yes No
*LOCATION ADDRESS	*CITY	*STATE	*ZIP CODE	*COUNTY
*MAILING ADDRESS SAME AS LOCATION ADDRESS	*CITY	*STATE	*ZIP CODE	*COUNTY
PRIMARY PHONE	WORK PHONE	CELL PHONE	VIDEO PHONE	FAX NUMBER	TDD/TTY
EMAIL ADDRESS	*PREFERRED CORRESPONDENCE METHOD Mail E-Mail
*PREFERRED CONTACT METHOD Location Address Cell Phone Mailing Address Fax Number Primary Phone E-mail Work Phone Video Phone	LANGUAGE PREFERENCE English Spanish Other:	COMMUNICATION NEEDS Foreign Language Interpreter Braille Sign Language Interpreter Large Print Other:
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CONTACT PERSON (other than yourself)
NAME	RELATIONSHIP	PHONE
VOTER REGISTRATION (to be completed by OVR)
Application Mailed/Delivered - Client Declined to Apply for Registration Application Mailed/Delivered - Agency Participation Under the Age of 18 Declined to Apply, Already Registered Participant Not Eligible to Vote
EDUCATION RECORD
*LEVEL OF EDUCATION AT APPLICATION No formal schooling Special education - enrolled Elementary education – enrolled (Grades 1-8) Special Education Certificate of Completion/Diploma attained Elementary education – completed (Grades 1-8) Post-Secondary Education, no degree or certificate Secondary education – enrolled (Grade 9) Post-Secondary Education – enrolled (1 academic year) Secondary education completed through Grade 9 Post-Secondary Education – enrolled (2 academic year) Secondary education – enrolled (Grade 10) Post-Secondary Education – enrolled (3 academic year) Secondary education completed through Grade 10 Post-Secondary Education – enrolled (4 academic year) Secondary education – enrolled (Grade 11) Associate Degree Secondary education completed through Grade 11 Bachelor’s Degree Secondary education – enrolled (Grade 12) Master’s Degree Secondary education completed through Grade 12; Career training – does not lead to post-secondary credential no high school diploma Career training – leads to post-secondary credential State adult high school – enrolled (high ASE level) Any Degree above a Master’s – e.g. Ph.D., Ed.D., J.D., M.D. High school diploma or equivalency certificate (GED) Vocational/Technical Certificate Special education – no certificate of completion/diploma) Vocational/Technical License
*STATUS OF INDIVIDUAL WITH A DISABILITY IN SECONDARY EDUCATION AT THE TIME OF APPLICATION (CHECK ONE) (to be completed by OVR): The individual is… The individual is a student… NOT a student with a disability in secondary education Covered by Section 504 of the Rehabilitation Act Receiving services under an IEP Not covered by Section 504 of the Rehabilitation Act not receiving services under an IEP
*STUDENT WITH A DISABILITY? (to be completed by OVR): Yes No	*ANTICIPATED COMPLETION/GRADUATION DATE (IF APPLICABLE) (mm/yyyy)
NAME OF SCHOOL: CITY, STATE:	DEGREE	START (mm/yyyy)	END (mm/yyyy)
NAME OF SCHOOL: CITY, STATE:	DEGREE	START (mm/yyyy)	END (mm/yyyy)
NAME OF SCHOOL: CITY, STATE:	DEGREE	START (mm/yyyy)	END (mm/yyyy)

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WORK RECORD LIST (PLEASE LIST MOST RECENT JOB FIRST)
EMPLOYER 1	JOB TITLE	ONET CODE: (to be completed by OVR)	FOR THIS JOB WERE/ARE YOU SELF-EMPLOYED? Yes Yes – Business Enterprise No
EMPLOYER NAME, CITY, STATE	START (mm/yyyy)	END (mm/yyyy)	STILL WORKING? Yes No	HOURS /Wk
WORK STATUS Apprentice Permanent Summer Contract Seasonal Temporary Full-time Subsidized Work Part-time Employment Experience	REASON FOR LEAVING Health/Medical Reasons Laid Off, with Return Date Involuntary Termination Retirement Laid Off, No Return Date Other:
HOW DOES YOUR DISABILITY KEEP YOU FROM RETURNING TO THIS JOB?
JOB RESPONSIBILITIES
EMPLOYER 2	JOB TITLE	ONET CODE: (to be completed by OVR)	FOR THIS JOB WERE/ARE YOU SELF-EMPLOYED? Yes Yes – Business Enterprise No
EMPLOYER NAME, CITY, STATE	START (mm/yyyy)	END (mm/yyyy)	STILL WORKING? Yes No	HOURS /Wk
WORK STATUS Apprentice Permanent Summer Contract Seasonal Temporary Full-time Subsidized Work Part-time Employment Experience	REASON FOR LEAVING Health/Medical Reasons Laid Off, with Return Date Involuntary Termination Retirement Laid Off, No Return Date Other:
HOW DOES YOUR DISABILITY KEEP YOU FROM RETURNING TO THIS JOB?
JOB RESPONSIBILITIES
EMPLOYER 3	JOB TITLE	ONET CODE: (to be completed by OVR)	FOR THIS JOB WERE/ARE YOU SELF-EMPLOYED? Yes Yes – Business Enterprise No
EMPLOYER NAME, CITY, STATE	START (mm/yyyy)	END (mm/yyyy)	STILL WORKING? Yes No	HOURS /Wk
WORK STATUS Apprentice Permanent Summer Contract Seasonal Temporary Full-time Subsidized Work Part-time Employment Experience	REASON FOR LEAVING Health/Medical Reasons Laid Off, with Return Date Involuntary Termination Retirement Laid Off, No Return Date Other:
HOW DOES YOUR DISABILITY KEEP YOU FROM RETURNING TO THIS JOB?
JOB RESPONSIBILITIES
CURRENT EMPLOYMENT STATUS (to be completed by OVR)
If working (select one below)… If not working (select one below)… Competitive Integrated Employment Student in secondary education Competitive Integrated Employment with supports All other students Extended employment Trainee, intern, or volunteer Self-employment (except BEP) Other State agency-managed Business Enterprise Program (BEP) Employed, but: Pending layoff/termination of employment/WARN issued/employer closure/transitioning service member
*IS THIS A WORK RETENTION CASE? (to be completed by OVR): Yes No	*WEEKLY EARNINGS (to be completed by OVR): $	*HOURS WORKED PER WEEK (to be completed by OVR): hours/week

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MILITARY RECORD LIST (IF APPLICABLE)
BRANCH OF SERVICE	ENTRY DATE	SEPARATION DATE	TYPE OF DISCHARGE	HAVE YOU BEEN FULLY DISCHARGED FROM THE RESERVES OR NATIONAL GUARD: Yes No
AS A MEMBER OF THE ARMED FORCES OR A RESERVE COMPONENT, HAVE YOU SERVED OR WERE YOU CALLED TO ACTIVE DUTY DURING A CAMPAIGN OR EXPEDITION FOR WHICH A CAMPAIGN BADGE/EXPEDITIONARY MEDAL OR ARMED FORCES SERVICE MEDAL WAS AUTHORIZED?	Yes No
RESPONSIBILITIES
*I CERTIFY THAT I HAVE SERVED IN THE ARMED FORCES OF THE UNITED STATES OF AMERICA
CERTIFICATION/LICENSE RECORD (IF APPLICABLE)
CERTIFICATION/LICENSE TITLE	CERTIFICATION/LICENSED BY
*STATE	DATE ISSUED	DOES IT EXPIRE? IF YES, DATE OF EXPIRATION: Yes No
ADDITIONAL CERTIFICATION INFORMATION:
HOUSEHOLD COMPOSITION
LIST PEOPLE LIVING IN THE HOUSEHOLD:
FIRST AND LAST NAME	DATE OF BIRTH	RELATIONSHIP	EMPLOYER
*FAMILY SIZE (NUMBER OF DEPENDENTS IN YOUR FAMILY INCLUDING YOURSELF):
LIVING ARRANGEMENTS (to be completed by OVR)
Private Residence (Independent or with Family/Other Person) Adult Correctional Facility Community Residential/Group Home Halfway House Rehabilitation Facility Substance Abuse Treatment Center Mental Health Facility Homeless Shelter Nursing Home Other
FINANCIAL (to be completed by OVR)
*HOW MUCH MONEY DO YOU GET EACH MONTH (INCLUDING MONEY YOU EARN AND ANY OTHER INCOME YOU HAVE TO SPEND? $
PRIMARY INCOME SOURCE Personal Income (employment earnings, interest, dividends, rent, retirement, Social Security retirement, etc.) Family and Friends (someone else’s earnings, someone else’s unemployment check, etc.) Public Support (SSI, SSDI, Public Welfare, Worker’s Compensation, Unemployment Compensation, Veteran Disability, etc.) All Other Sources (private disability insurance, private charities, etc.) Other Income Source: Homeless Shelter Nursing Home Other

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PUBLIC SUPPORT SOURCE (to be completed by OVR)	SUPPLEMENTAL SECURITY INCOME (SSI)	$
SOCIAL SECURITY DISABILITY INSURANCE (SSDI)	$
TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF)	$
GENERAL ASSISTANCE (GA)	$
VETERAN’S DISABILITY BENEFITS	$
WORKER’S COMPENSATION	$
REFUGEE CASH ASSISTANCE (RCA)	$
OTHER PUBLIC SUPPORT:	$
AGENCY INVOLVEMENT (IF APPLICABLE)
AGENCY NAME	SERVICE RECEIVED	COUNSELOR/CASE MANAGER
PRIMARY AGENCY INVOLVEMENT (to be completed by OVR)
CODES: Primary Agency Involvement (1), Secondary Agency Involvement (2), Additional Agency Involvement (3) Choose up to three (3) types of service providers/funding sources that were provided to the individual during the beginning of the quarter:
Not provided services or funding from any program or organization Mental Health Provider (Public or Private) Adult Education/Literacy Program (Dept. of Education) One-Stop Operators Adult, Dislocated Worker/Youth Program (Dept. of Labor) Public Housing Authority American Indian VR Services Program Social Security Administration (Disability Determination Centers for Independent Living Service or District Office) Child Protective Services State Department of Correction/Juvenile Justice Community Rehabilitation Programs State Employment Service Agency Consumer Organization or Advocacy Group Veteran’s Benefit Administration Education Institution (Elementary/Secondary) Veteran’s Health Administration Education Institution (Post-Secondary) Wagner-Peyser Employment Employers Worker’s Compensation Employment Networks (not otherwise listed) Other DOL Programs under WIOA (Job Corps, etc.) Federal Student Aid Other Sources Intellectual and Developmental Disabilities Agencies Other State Agencies Medical Health Provider (Public or Private) Other VR State Agencies Other Welfare Agency (State or Local Government)
DISABILITY INFORMATION (to be completed by OVR)
IMPAIRMENT/CAUSE CODE COMBINATION(S)
*IMPAIRMENT CODE	*CAUSE CODE	*YEAR OF ONSET	*DX/COMMENTS
PRIMARY
SECONDARY 1
SECONDARY 2
SECONDARY 3
SECONDARY 4
*SEVERITY STATUS (to be completed by OVR) Most Significantly Disabled (MSD) Significantly Disabled (SD) Not Significantly Disabled (NSD) Undetermined (U)

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DISABILITY INFORMATION
WHAT IS YOUR DISABILITY?	YEAR OF ONSET:
*HOW DOES YOUR DISABILITY INTERFERE WITH WORKING OR MAINTAINING YOUR INDEPENDENCE?	DOES YOUR DOCTOR/ THERAPIST/ PSYCHIATRIST SUPPORT YOUR DESIRE TO RETURN TO WORK? Yes No
*WHAT DO YOU THINK OVR CAN DO TO HELP YOU GET OR KEEP A JOB, OR MAINTAIN YOUR INDEPENDENCE?	WHAT JOBS OR CAREERS INTEREST YOU?
LEGAL HISTORY (IF APPLICABLE)
HAVE YOU EVER BEEN CONVICTED OF… A Felony? Yes No A Misdemeanor? Yes No	IF YES, WHAT IS YOUR LEGAL STATUS NOW? Probation Work Release Parole Pending Community Corrections Other:
PROBATION/PAROLE OFFICER’S NAME:	PROBATION/PAROLE OFFICER’S PHONE: Extension:
DRUG AND ALCOHOL HISTORY (IF APPLICABLE)
DO YOU NOW, OR HAVE YOU EVER USED ALCOHOL OR OTHER DRUGS TO THE EXTENT THAT IT CAUSED LEGAL, PERSONAL, OR EMPLOYMENT PROBLEMS? Yes No
IF YES, PLEASE DESCRIBE:
HOW LONG HAVE YOU USED ALCOHOL/ DRUGS?	WHAT IS YOUR DRUG OF CHOICE?	LAST TIME ALCOHOL/DRUGS USED?
WHAT ARE YOU CURRENTLY DOING TO MAINTAIN SOBRIETY?
TRANSPORTATION
DO YOU HAVE… A Driver’s License? Yes No A Car? Yes No	IS PUBLIC TRANSPORTATION AVAILABLE? Yes No IS OTHER TRANSPORTATION AVAILABLE? Yes No	IF AVAILABLE, ARE THESE MODES OF TRANSPORTATION ACCESSIBLE? Yes No
HAVE YOU EVER BEEN CONVICTED OF A D.U.I.? Yes No	SPECIFY TYPE OF PUBLIC TRANSPORTATION USED:

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MEDICAL INFORMATION
We need information about your physical and mental health status to help determine your eligibility and how your dis-ability interferes with your ability to work/live independently. Answers to these questions help us obtain the documents that prove you have a disability. Please bring any medical information or records you have to your initial interview.
MEDICAL EXAMINATION HISTORY
PRIMARY CARE PHYSICIAN
PHYSICIAN NAME:	LAST APPOINTMENT DATE: (MM/YYYY)	NEXT APPOINTMENT DATE: (MM/YYYY)
PHYSICIAN ADDRESS:
REASON FOR VISIT:
MEDICAL SPECIALIST #1
SPECIALIST NAME:	LAST APPOINTMENT DATE: (MM/YYYY)	NEXT APPOINTMENT DATE: (MM/YYYY)
SPECIALIST ADDRESS:	SPECIALTY AREA
REASON FOR VISIT:
MEDICAL SPECIALIST #2
SPECIALIST NAME:	LAST APPOINTMENT DATE: (MM/YYYY)	NEXT APPOINTMENT DATE: (MM/YYYY)
SPECIALIST ADDRESS:	SPECIALTY AREA
REASON FOR VISIT:
MEDICAL SPECIALIST #3
SPECIALIST NAME:	LAST APPOINTMENT DATE: (MM/YYYY)	NEXT APPOINTMENT DATE: (MM/YYYY)
SPECIALIST ADDRESS:	SPECIALTY AREA
REASON FOR VISIT:
MEDICAL SPECIALIST #4
SPECIALIST NAME:	LAST APPOINTMENT DATE: (MM/YYYY)	NEXT APPOINTMENT DATE: (MM/YYYY)
SPECIALIST ADDRESS:	SPECIALTY AREA
REASON FOR VISIT:
MEDICATIONS
ARE YOU TAKING ANY MEDICATIONS? Yes No IF YES, PLEASE LIST BELOW:
NAME	DOSAGE	REASON	PERSONAL SIDE EFFECTS

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MEDICAL INSURANCE
TYPE OF INSURANCE	INSURANCE ID #	CARRIER
MEDICAID
MEDICARE
MA FOR WORKERS WITH DISABILITIES
PRIVATE INSURANCE (THROUGH CURRENT EMPLOYER)
PRIVATE INSURANCE (THROUGH OWN EMPLOYER)
PRIVATE INSURANCE (OTHER MEANS)
WORKER’S COMPENSATION
STATE OR FEDERAL AFFORDABLE CARE ACT EXCHANGE
ARE YOU RECEIVING DISABILITY PAYMENTS FROM ANY OTHER SOURCE? Yes No	IF YES, NAME OF COMPANY PAYING BENEFITS: MONTHLY AMOUNT: $
ARE YOU INVOLVED IN ANY LAWSUITS RELATED TO YOUR DISABILITY? Yes No IF YES, PLEASE EXPLAIN:
ATTORNEY NAME	ATTORNEY ADDRESS
CITY	STATE	ZIP CODE
MEDICAL HISTORY
DO ANY OF THE FOLLOWING INTERFERE WITH YOUR ABILITY TO WORK/LIVE INDEPENDENTLY?
SENSORY	PHYSICAL TOLERANCE
Cooking safely and Moving safely (at home, efficiently work, etc.) Dialing telephone numbers Reading printed materials Fainting Seeing a clock or watch Hallucinations/delusions Seeing faces/recognizing Hearing people Housekeeping Speaking Identifying money Using appliances with Identifying colors numbers and dials Laundry Watching television Writing	Balancing Reading typewritten material Chest pain Shortness of breath Chronic cough Sitting Climbing stairs Skin problems Digestion Sleep Energy/stamina Standing/walking/running Gynecological problems Swelling of hands/legs Kneeling Weakness/pain in hands/arms Lifting/bending Weakness/pain in legs/feet Numbness
COGNITIVE/EMOTIONAL	HAVE YOU EVER HAD, OR BEEN TOLD YOU HAVE
Concentrating Depression Enjoying hobbies Ever been unconscious Getting along with people Health maintenance Learning Nervousness (anxiety/panic) Reading/writing/math Remembering Stress tolerance	Alcohol problems Urinary problem, kidney/ Asthma/lung or end stage renal disease or respiratory disease genitourinary disorders Blood disease Mental impairments Cancer Musculoskeletal arthritis, Developmental disability rheumatism, amputations, Diabetes fractures, injuries resulting in Drug problem permanent loss, impairment Eating disorder of limb function Gastrointestinal problems Neurological impairments, Heart trouble or cardiac/ disorders due to stroke, circulatory seizures, Parkinson’s, or other Hepatitis Psychiatric or emotional disorder High blood pressure Tuberculosis HIV/AIDS Other:

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MEDICAL HISTORY (continued)
DO YOU USE A CANE, BRACE, WHEELCHAIR, HEARING AID, LOW VISION AID OR OTHER ASSISTIVE DEVICE? Yes No IF YES, PLEASE SPECIFY:
CAN YOU TRAVEL INDEPENDENTLY? Yes No IF NO, PLEASE SPECIFY:
VISUAL INFORMATION (IF APPLICABLE)
VISUAL ACUITY (WITH BEST CORRECTION) Normal Restricted 20 degrees or less Somewhat restricted Unknown	VISUAL ACUITY OD	VISUAL ACUITY OS
VISUAL FUNCTIONING (IF YOU INDICATED YOUR VISUAL FUNCTIONING IS NORMAL, YOU MAY SKIP THIS SECTION)
DO YOU KNOW THE NAME OF YOUR EYE CONDITION AND WHAT THAT MEANS? Yes No
PLEASE DESCRIBE WHAT YOU CAN SEE:
HOW IS YOUR EYE CONDITION TREATED?
HAVE YOU HAD VISION SERVICES BEFORE? Yes No IF YES, WHAT KIND AND WHERE?
ARE THERE CERTAIN SKILLS OR ACTIVITIES THAT YOU “LOST” DUE TO YOUR VISUAL IMPAIRMENT THAT YOU WOULD LIKE TO IMPROVE OR DO AGAIN?