Form 80 Vr 01 A PDF Details

Form 80 Vr 01 A is a document used in the fulfillment of business contracts. This form is used to provide information about the parties involved in the contract, as well as their agreement to the terms of the contract. The form must be completed and signed by both parties for the contract to be legally binding. By understanding how to complete and use Form 80 Vr 01 A, you can ensure that all your business contracts are done correctly and legally.

If you want to first understand how much time you need to fill out the form 80 vr 01 a and the number of pages it's got, here's some basic data that may be helpful.

QuestionAnswer
Form NameForm 80 Vr 01 A
Form Length4 pages
Fillable?Yes
Fillable fields17
Avg. time to fill out4 min 28 sec
Other names80 vr 01 a and b combined 4 12 participant information application for vocational rehabilitation services ohio

Form Preview Example

Ohio

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Participant Information/Application for

Commission

 

 

 

 

 

 

Vocational Rehabilitation Services

PLEASE PRINT

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last)

 

 

 

First

 

 

M.l.

Suffix (i.e., Jr.)

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (Street)

 

 

 

 

 

City

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone No.

 

 

 

Alternate Phone No.

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

County of Residence

 

E-mail Address

 

 

 

 

 

 

 

 

Are you referring yourself? Yes No If not, who is referral source?

 

 

 

 

 

 

 

 

What is your disability?

 

 

 

 

 

 

 

 

 

 

 

 

 

Where do you live?

 

I-1 m • h

 

 

 

 

 

 

 

 

Private residence

 

W Halfwa^ hoij °

r*

 

EZ1 Homeless shelter

 

Community residential/group home

H

 

Assisted living center

m n.u.k'iU 4 ■■■.

 

Adult correctional facility

 

 

 

F=j

 

Mental' health facility

 

D Substance abuse/treatment ctr

 

 

 

 

 

Are you a U.S. Citizen? Yes No If no, please list your immigration status:

 

 

 

 

 

 

 

 

Race/ethnicity:

 

 

 

 

 

 

 

 

 

Would you like to register to vote?

White

 

 

Hispanic/Latino

 

 

 

 

 

 

 

 

 

 

Yes No

 

Asian

 

 

American Indian/Alaska Native

 

 

 

 

 

Already registered

Black/African-American

 

Native Hawaiian/Other Pacific Islander

 

 

 

 

 

 

 

What is your highest grade completed?

 

 

 

 

 

 

] High school graduate or equivalency (Regular GED)

No formal education

 

 

 

 

 

 

 

Post-secondary education, no degree

 

] Elementary education (1-8)

 

 

 

 

 

 

] Associate degree or vocational/technical certificate

Secondary education, no diploma (9-12)

 

 

 

 

 

 

Bachelor’s degree

 

] Special education certificate of completion/diploma of attendance

 

 

Master’s degree or higher

 

Are you currently enrolled in high school?

Yes No

 

 

 

 

 

 

 

 

Have you ever received services under an individualized education plan (IEP)?

Yes No

 

 

 

 

 

Are you currently working? Yes No What is your hourly wage?

 

 

 

How many hours per week?

How do you financially support yourself?

 

 

 

 

Which types of medical insurance do you receive?

Personal income

 

 

 

 

 

Check all that apply.

 

Family and friends

 

 

 

 

 

 

 

Medicaid

Medicare

 

Public support (Check all that apply): DSSI, SSDI,

 

 

 

Private

None

 

□TANF, Food stamps

 

 

 

 

 

 

 

 

 

 

 

 

Other sources

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex: Male Female

 

 

 

 

 

Are you a Veteran? Yes No

 

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.

 

 

 

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.

 

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.

 

 

I acknowledge that in applying for services, RSC may obi

ain or release confidential personal information about me:

 

To purchase services for me.

 

 

In collaboration with RSC Contractors and Part

ners (for example Vocational Rehabilitation Public & Private Partnerships) on my behalf.

To report my progress to the agency who refer

red me to RSC.

 

When required by law and to facilitate the adm

nistration of the Rehabilitation Act.

 

To do research to improve the lives of people v

vith disabilities.

 

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

 

SSI benefits, if applicable.

 

 

To other state agencies, if applicable.

 

 

Signature of Applicant (If under 18, parent/guardian must also sign below)

Date

 

 

 

Signature of Parent or Guardian

 

Date

 

 

 

 

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:

 

 

Original - Counselor

 

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

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entering details in Form 80 Vr 01 A part 1

Fill in the MedicaidPrivate, TANFFoodstamps, MedicareNone, AreyouaVeteranYesNo, PhoneNo, Address, sextypeofdisabilityorinanymanner, tePartnershipsonmybehalf, applyingfororamarecipientofSSDIor, SignatureofParentorGuardian, Date, and Date fields with any content that are asked by the application.

Form 80 Vr 01 A MedicaidPrivate, TANFFoodstamps, MedicareNone, AreyouaVeteranYesNo, PhoneNo, Address, sextypeofdisabilityorinanymanner, tePartnershipsonmybehalf, applyingfororamarecipientofSSDIor, SignatureofParentorGuardian, Date, and Date blanks to fill out

Type in the significant details when you find yourself within the SignatureofParentorGuardian, Date, Initials, OriginalCounselor, CopyConsumer, VRAJAWSAccessible, and Effective area.

Completing Form 80 Vr 01 A step 3

Within the box VRBJAWSaccessible, and Effective, include the rights and responsibilities of the parties.

part 4 to completing Form 80 Vr 01 A

Finalize the form by analyzing all these areas: toafairhearing.

stage 5 to finishing Form 80 Vr 01 A

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