Form Vr 04 PDF Details

The Application for Vocational Rehabilitation Services, identified as the VR-04 form, serves as a critical document for individuals seeking assistance from The University of the State of New York's State Education Department, specifically through its Office of Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR). This comprehensive form is designed to capture essential details about the applicant, including personal information, contact details, social security number, and mailing address. It delves deeper by requesting specifics about the applicant’s disability, the nature of their employment barrier, marital status, and any services they might have previously received from ACCES-VR or its predecessor. Additionally, the VR-04 form explores the applicant's employment history, educational background, and the support and benefits they are currently receiving, which could impact their eligibility and the type of services they might require. The form also emphasizes the rights of applicants, underscoring the confidentiality of their information and the nondiscrimination policy upheld by the State Education Department. This initial step of completing and returning the VR-04 form is pivotal for individuals with disabilities to access specialized services aimed at enhancing their career opportunities and overall quality of life.

QuestionAnswer
Form NameForm Vr 04
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaccess vr forms 571 575, acces vr forms, acces vr application forms, access vr 115

Form Preview Example

Please return the completed form to:

The University of the State of New York

 

THE STATE EDUCATION DEPARTMENT

 

Office of Adult Career and Continuing

 

Education Services-Vocational Rehabilitation

 

(ACCES-VR)

 

Application for VR Services

 

VR-04 (7/14)

Please print or type all entries

NAME

Last

First

 

Middle Initial

 

 

 

If you have been known by another name, enter here:

Last

First

GENDER

Male

Female

Middle Initial

HOME ADDRESS Street

Apartment Number

City

State

Zip +4 Code

County

SOCIAL SECURITY NUMBER

--

If your MAILING ADDRESS is different than your home address, please complete the mailing address information below.

MAILING ADDRESS

Street

Apartment Number

 

 

 

 

City

State

Zip +4 Code

County

PHONE NUMBER(S) where we can reach you or leave a message:

Area code

 

Area code

 

1. (

)

 

2. (

)

 

Home

Cell

Other

Home

Cell

Other

Email:______________________________________

Best time to call 1.

2.

DATE OF BIRTH

Month Day Year

--

Race/Ethnicity-Choose ALL that apply. If left blank ACCES Will complete. If Hispanic or Latino is checked, please check additional box.

American Indian or Alaska Native

Asian (includes Indian Subcontinent) Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

What is your disability?

Who referred you to us?

MARITAL STATUS: (Check Box)

Married Widowed Divorced

 

Separated

Never Married

 

 

 

I hereby apply for rehabilitation services:

Signature of applicant, parent, or legal guardian.

 

Date________________

 

 

X (Sign here.)

  Please answer the questions below and on the back of this form.  

You do not have to answer these questions now, but your answers will help ACCES-VR process your application.

Have you ever received services from ACCES-VR or its former name, the Office of Vocational and Educational Services for

Individuals with Disabilities (VESID)?

Yes

No

Are you now receiving services from one or more agencies? ……………………………………….

Yes

No

If you answered yes, indicate agency names(s), address(es) and contact person(s):

 

 

(1)

 

 

(2)

 

 

Describe how your disability limits your ability to work.

 

 

What services are you seeking from ACCES-VR?

 

Are you disabled because of a work-related injury?

 

Yes

No

Are you a veteran?

 

 

 

 

Do you use any assistive devices or aids?

 

 

Yes

No

Yes

No

 

 

 

 

 

 

Are you a citizen of the United States?

 

 

Do you have a NYS driver’s license?

 

 

Yes

No

 

 

 

 

Yes

No

 

 

 

 

Do you have a driver’s license from a state other than New York?

Yes

No

If no, are you legally permitted to work in

 

Do you have Access to a motor vehicle?

 

 

Yes

No

this country?

 

Yes

No

 

 

 

 

 

 

 

 

 

Do you use public transportation?

 

 

Yes

No

Check the benefits you now receive:

 

 

 

 

SSI

SSDI

Workers Compensation

 

 

 

 

 

 

 

 

 

Are you able to leave your home?

 

 

Yes

No

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)

 

 

___College

____Graduate School

___Doctorate

 

GED or High School Equivalency Diploma

Yes

No

 

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 for or receiving rehabilitation services have the right to have any actions or decisions 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, religion, creed, disability, marital status, pregnancy, veteran status, national origin, race, gender, genetic predisposition or carrier status, or sexual orientation 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.

How to Edit Form Vr 04 Online for Free

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Step 1: Find the button "Get Form Here" on the following site and press it.

Step 2: Right now, you can start modifying the acces vr application. Our multifunctional toolbar is at your disposal - add, remove, adjust, highlight, and carry out several other commands with the words and phrases in the file.

The next parts are what you are going to fill in to obtain the ready PDF document.

filling out acces vr application forms part 1

Type in the demanded information in the space Home, Cell, Other, Home, Cell, Other, Email, RaceEthnicityChoose ALL that apply, American Indian or Alaska Native, Hispanic or Latino Native Hawaiian, What is your disability, Who referred you to us, MARITAL STATUS Check Box, Married, and Widowed Divorced.

acces vr application forms Home, Cell, Other, Home, Cell, Other, Email, RaceEthnicityChoose ALL that apply, American Indian or Alaska Native, Hispanic or Latino Native Hawaiian, What is your disability, Who referred you to us, MARITAL STATUS Check Box, Married, and Widowed Divorced fields to fill out

Identify the valuable information in the Describe how your disability part.

Filling in acces vr application forms part 3

You will have to spell out the rights and responsibilities of both sides in part What services are you seeking from, Are you disabled because of a, Do you use any assistive devices, Do you have a NYS drivers license, Do you have a drivers license from, Do you have Access to a motor, Do you use public transportation, Are you able to leave your home, Yes, Yes, Yes, Yes, Yes, Yes, and Yes.

acces vr application forms What services are you seeking from, Are you disabled because of a, Do you use any assistive devices, Do you have a NYS drivers license, Do you have a drivers license from, Do you have Access to a motor, Do you use public transportation, Are you able to leave your home, Yes, Yes, Yes, Yes, Yes, Yes, and Yes blanks to fill out

Finalize by analyzing the next sections and preparing them as needed: List the highest grade you have, GED or High School Equivalency, Yes, College, Graduate School Doctorate, Special Education, Yes, No Do you now attend high school, Yes, Indicate college degrees earned, Name and address of school you, Address, List below other people in your, Full Name, and Age.

Completing acces vr application forms step 5

Step 3: Hit the "Done" button. At that moment, you may transfer the PDF document - save it to your device or send it through electronic mail.

Step 4: Generate copies of the file - it can help you remain away from possible future problems. And don't worry - we do not publish or view your data.

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