Ohio |
nciiauiiiLciLiuii ocivilc^ |
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Participant Information/Application for |
Commission |
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Vocational Rehabilitation Services |
PLEASE PRINT |
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Name (Last) |
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First |
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M.l. |
Suffix (i.e., Jr.) |
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Social Security Number |
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Home Address (Street) |
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City |
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State |
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Zip Code |
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Home Phone No. |
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Alternate Phone No. |
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Date of Birth |
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County of Residence |
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E-mail Address |
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Are you referring yourself? Yes No If not, who is referral source? |
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What is your disability? |
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Where do you live? |
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I-1 m • h |
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Private residence |
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W Halfwa^ hoij ° |
r* |
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EZ1 Homeless shelter |
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Community residential/group home |
H |
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Assisted living center |
m n.u.k'iU 4 ■■■. |
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Adult correctional facility |
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F=j |
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Mental' health facility |
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D Substance abuse/treatment ctr |
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Are you a U.S. Citizen? Yes No If no, please list your immigration status: |
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Race/ethnicity: |
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Would you like to register to vote? |
White |
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Hispanic/Latino |
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Yes No |
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Asian |
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American Indian/Alaska Native |
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Already registered |
Black/African-American |
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Native Hawaiian/Other Pacific Islander |
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What is your highest grade completed? |
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] High school graduate or equivalency (Regular GED) |
No formal education |
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Post-secondary education, no degree |
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] Elementary education (1-8) |
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] Associate degree or vocational/technical certificate |
Secondary education, no diploma (9-12) |
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Bachelor’s degree |
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] Special education certificate of completion/diploma of attendance |
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Master’s degree or higher |
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Are you currently enrolled in high school? |
Yes No |
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Have you ever received services under an individualized education plan (IEP)? |
Yes No |
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Are you currently working? Yes No What is your hourly wage? |
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How many hours per week? |
How do you financially support yourself? |
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Which types of medical insurance do you receive? |
Personal income |
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Check all that apply. |
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Family and friends |
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Medicaid |
Medicare |
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Public support (Check all that apply): DSSI, SSDI, |
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Private |
None |
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□TANF, Food stamps |
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Other sources |
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Sex: Male Female |
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Are you a Veteran? Yes No |
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Contact person(s): If you complete this section, you are permitting RSC to disclose to the contact person that you have applied for services.
Name |
Address |
Phone No. |
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This application will be considered complete when it is in tialed and dated by VR Staff or VR Contractor at the time |
of your appointment. |
The State of Ohio is committed to good privacy practices |
As such, we are disclosing that in order to fully process your application, verify your eligibility and |
provide vocational rehabilitation services, the Rehabilitation Services Commission (RSC) may need to access perse3nal information about you, such as your Social Security Number, which is maintained by the Com mission. By signing this application, you are requesting theit RSC access any personal information
necessary |
to process your application, determine eligibili y and provide services. Please note that RSC will continues to protect any non-public, confidential |
personal information maintained about you from release |
o the public or unauthorized third parties. |
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RSC does not discriminate against any applicant for serv ces on the basis of age, color, creed, national origin, race |
sex, type of disability or in any manner |
prohibited by law. |
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I acknowledge that in applying for services, RSC may obi |
ain or release confidential personal information about me: |
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To purchase services for me. |
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In collaboration with RSC Contractors and Part |
ners (for example Vocational Rehabilitation Public & Private Partnerships) on my behalf. |
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To report my progress to the agency who refer |
red me to RSC. |
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When required by law and to facilitate the adm |
nistration of the Rehabilitation Act. |
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To do research to improve the lives of people v |
vith disabilities. |
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To the Social Security Administration (SSA) an |
d/or Division of Disability Determination (DDD) when 1 am |
applying for or am a recipient of SSDI or |
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SSI benefits, if applicable. |
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To other state agencies, if applicable. |
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Signature of Applicant (If under 18, parent/guardian must also sign below) |
Date |
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Signature of Parent or Guardian |
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Date |
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RSC Use Only: I have explained RSC services and procedures, consumer rights, confidentiality, the Client Assistance Program (CAP), and the right to register to vote: provided Consumer Fact Sheet for Application about rights, duties and informed choice; and provided the consumer with a copy of this application. I have done so in the preferred mode of
rnmmi miration of this consumer 1 certify that this application is accurate- |
Initials |
Date How was this form received? I“l Flectronically |~| In Person |
Mail Phone Other: |
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Original - Counselor |
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Copy - Consumer |
80-VR-01 .A (JAWS Accessible) |
Effective 04/02/12 |
Ohio |
Rehabilitation Services |
Commission |
Vocational Rehabilitation (VR)
Application Fact Sheet
What does completing an Application mean?
Once an individual has completed an application to receive vocational rehabilitation (VR) services from the Ohio Rehabilitation Services Commission (RSC) or a VR Contractor, it indicates that the individual is interested in obtaining and/or maintaining employment.
What comes next?
The next step will be to determine if the individual is eligible for services. To be eligible for VR services, the individual must: 1) have a physical or mental impairment [i.e. disability which causes a substantial impediment (i.e. barrier) to employment]; 2) be able to benefit in terms of an employment outcome from VR services; and 3) require VR services in order to prepare for, engage in, or retain gainful employment.
Eligibility determination will be made based upon disability related records provided by the individual or obtained from treatment providers or other professionals. Additional assessments may be necessary.
If the individual is a Social Security beneficiary under Titles 11/XVI, they are presumed to be eligible for VR services and Significantly Disabled, as long as they want to work.
Federal law requires that eligibility must be determined within 60 days of application for services, unless the individual agrees to extend this timeframe. Only services for eligibility determination may be provided during this time.
If the individual is determined eligible, the individual and the VR Counselor or VR Coordinator will develop a plan to help the individual obtain and/or maintain employment in the individual's chosen field.
Individual’s Rights and Duties
The individual has the right to bring a friend, parent, guardian, advocate or other representative to any meetings with VR staff or VR Contractor.
VR Staff and VR Contractors keep the individual’s information and records strictly confidential unless the individual consents, in writing, to release them. This includes sharing information with treatment providers and family members. VR Staff or VR Contractors may, however, release information about the individual: 1) to obtain services for them, 2) to report progress to the agency that referred them [if applicable], 3) if/when required by law, 4) to do research to improve the lives of people with disabilities, and 5) to obtain wage verification.
An individual should always discuss disagreements about their case with the VR Staff or VR Coordinator.
RSC values consumers and informed choice in the vocational rehabilitation process. Sometimes a VR Counselor or VR Coordinator and a consumer are unable to agree on an employment goal or a service. When this occurs, the consumer may seek resolution through the consumer appeal process.
The consumer may seek advocacy assistance with the appeal process by contacting the Client Assistance Program (CAP) of the Ohio Legal Rights Service (OLRS). OLRS can be reached by calling
614.466. 7264, or toll-free at 800. 282. 9181, or 800. 858. 3542 TTY, or by accessing the website at www.olrs.ohio.gov/need-our-help.
80-VR-01 .B (JAWS accessible) |
Effective 04/02/12 |
❖The consumer has 30 days1 from the date he or she has notice of the counselor’s decision that led to the disagreement to give written notice of an appeal to ORSC’s Executive Director. The Consumer Appeal Form shall be provided to the consumer and the consumer may use it, or provide other written notification to file an appeal. The appeal is sent to:
Executive Director Kevin L. Miller, c/o Legal Services Ohio Rehabilitation Services Commission
400 E. Campus View Blvd. 3LC Columbus, Ohio 43235
OR:
Send and e-mail to: RSC.ConsumerAppeals@ohio.gov
❖Upon receipt of the appeal, the Office of Legal Services (OLS) will schedule a fair hearing on or before the 60th day after the appeal is filed, and the consumer will receive a “save the date” letter. This does not necessarily mean that the consumer will go to fair hearing, but it will ensure timeliness if a fair hearing is ultimately what the consumer chooses to do.
❖The consumer may choose to either attend an informal administrative review or proceed directly to a fair hearing.
•Administrative Review - This is an informal meeting with the management representative to discuss the consumer’s concern and seek an immediate resolution. If this meeting does not result in resolution, the consumer may still choose to proceed to a fair hearing. This step does not extend the 60 day time limit to resolve the dispute. If the consumer chooses to attend an informal administrative review, the consumer will be contacted by a local area management representative to discuss the issue within 21 days. The consumer will receive a written summary of the meeting on or before 7 days from the date of the discussion. If the consumer does not like the outcome of the informal administrative review, the consumer has 14 days from the receipt of the administrative review summary to request a fair hearing. Failure to timely notify OLS of the request to proceed to fair hearing is viewed as a withdrawal of the disagreement.
•Fair Hearing - This is a formal hearing held in Columbus before a Hearing Officer. It is like a mini trial where each side can present documents as evidence and call witnesses to testify. The rules of evidence apply, and a court reporter will swear in all witnesses. ORSC is represented by the Attorney General’s Office. The Hearing Officer will issue a written decision that is binding for both the consumer and ORSC within 30 days of the hearing.
Please note that when the consumer chooses a fair hearing, the consumer may also request mediation. Mediation is a voluntary confidential process in which both parties agree to meet with an impartial mediator (not an ORSC staff member) to discuss resolution of the disagreement prior to the fair hearing. ORSC will send written notice to the consumer within 7 days if it is not willing to take the disagreement to mediation first.
In addition, a consumer has the right to file a civil rights complaint if they believe they are being treated unfairly because of age, color, national origin, ethnicity, race, sex, religion or type of disability. If this is the case, file a complaint with RSC’s Division of Human Resources, Equal Employment Opportunity office at 800. 282. 4536 or the Office for Civil Rights, U.S. Department of Education.
A consumer must always inform VR Staff or VR Contractor of the following:
1All timeframes reference calendar days unless specifically noted otherwise.
80-VR-01 .B (JAWS accessible) |
Effective 04/02/12 |
•name, address, e-mail or telephone number changes;
•being unable to keep an appointment, begin a program or dropping out of a program;
•becoming eligible for services and benefits (such as training, etc.) from another agency(ies); and
•obtaining a job, including the employer name, job title, the date started and salary.
Informed Choice: A consumer has the right to participate in decisions about their VR program with the support and guidance of the VR Counselor or VR Coordinator. The consumer will choose the people with whom the VR Counselor or VR Coordinator is permitted to contact concerning their case. The consumer may also provide input about where they will go for any necessary assessment services.
Helpful Hints
The more that the VR Counselor or VR Coordinator knows about the consumer, the better equipped they are in helping the consumer obtain a job. It is very important that the consumer is: 1) having open and honest discussions with the VR Counselor or VR Coordinator; 2) taking an active role in gathering necessary information; and 3) on time for all appointments.
To determine eligibility for VR services, the VR Counselor or VR Coordinator will need information explaining the individual's disability (or problems that they have had working). This information must come from a doctor or other treating professional. The individual can speed up the process by beginning to gather any records that could help the VR Counselor or VR Coordinator document eligibility. (If the individual doesn’t have this information available, the VR Counselor or VR Coordinator can help get it.)
An individual should keep all materials related to obtaining VR Services and going to work in one place, such as a special folder.
The individual needs to be sure to have a Social Security card and a photo ID as they will need to provide a copy of each in order to start working. If the individual doesn’t have these pieces of identification, inform the VR Counselor or VR Coordinator.
Glossary
Bureau of Services for the Visually Impaired (BSVI) - the area of RSC that assists Ohioans whose primary disabilities are vision- related.
Bureau of Vocational Rehabilitation (BVR) - the area of RSC that serves people with physical, mental and emotional disabilities.
Consumer - a person who is determined eligible and begins receiving vocational rehabilitation services.
Ohio Legal Rights Service and the Client Assistance Program (OLRS and CAP) - provide advocacy, information and referral services to consumers of RSC services.
Ohio Rehabilitation Services Commission (ORSC or RSC) - the state agency responsible for providing vocational rehabilitation services to Ohioans with disabilities (through BSVI and BVR).
Vocational Rehabilitation (VR) - specialized services that help people with disabilities get and/or keep a competitive job.
Vocational Rehabilitation Contractors (VR Contractors) - contractual providers who work with individuals who are interested in VR services, primarily VRP3 programs.
Vocational Rehabilitation Staff (VR Staff) - for the purposes of this fact sheet, caseload assistants, counselors and Vocational Rehabilitation Supervisors from the Bureau of Vocational Rehabilitation and the Bureau of Services for the Visually Impaired.
80-VR-01 .B (JAWS accessible) |
Effective 04/02/12 |
