Iowa Vocational Rehabilitation Services – Application Form
Please complete all sections. If you would like assistance with this form, do not hesitate to ask. If you need more space, please use an additional piece of paper.
A. Personal Information:_____________________________________________________________
First Name: ________________________________________________________________________
Middle/Maiden: _____________________________________________________________________
Last Name:_________________________________________________________________________
Social Security Number:____________________________ Date of Birth:_______________________
Home Address:______________________________________________________________________
City: ______________________________________State:_____________Zip:___________________
County:_____________________ Phone: (Home) (___)_______________ (Cell)(___)_____________
E-Mail:_______________________________ Age: _____________ Sex: _________M _________F
Race: Please check all that apply.
____White _____Native Hawaiian or Other Pacific Islander _______Asian
____American Indian or Alaska Native ______Black or African American
Ethnicity: Please check one.
Hispanic or Latina: ___ Yes ___ No
Marital Status: Please check at least one.
____Married, including common law ____Widowed ____Divorced ____ Separated
____Never Married
Living Arrangements:
___Private Residence ___Community Residence or Group Home ___Rehabilitation Facility
___Mental Health Facility ___Nursing Home ____Halfway House ____Homeless Shelter
___Substance Abuse Treatment Center ____Adult Correctional Facility ____Other
Do you have a legal guardian? _____Name:_____________________ Phone:_________________
Cultural/Religious Preferences:
Are there cultural or religious preferences we should be aware of that may affect vocational planning?
___ Yes ___ No
_________________________________________________________________________________
B. Referral Source and Rehabilitation Services:________________________________________
What services would you like to receive from Iowa Vocational Rehabilitation Services (IVRS)?
_______________________________________________________________________________
________________________________________________________________________________
Who referred you to IVRS?______________________________ Phone Number:(___)_____________
Is there someone outside of your household who would usually be able to help us contact you? First Name: _________________Last Name:_________________ Relationship:_______________
Phone: (Home):(___)____________ (Mobile):(___)______________ (Work):(___)_____________
E-Mail:_________________________ Address:_________________________________________
City:_______________________________________ State: ______________ Zip: _____________
First Name: _________________Last Name:_________________ Relationship:_______________
Phone: (Home):(___)____________ (Mobile):(___)______________ (Work):(___)_____________
E-Mail:_________________________ Address:_________________________________________
City:_______________________________________ State: ______________ Zip: _____________
C. Disability Information:____________________________________________________________
What is your disability, condition, or diagnosis?_________________________________________
________________________________________________________________________________
________________________________________________________________________________
What medications are you currently taking?
________________________________________________________________________________
________________________________________________________________________________
Do you take your medication as prescribed?_____ yes ____no, if no explain:__________________
________________________________________________________________________________
How does your disability affect your ability to work or find work?__________________________
________________________________________________________________________________
________________________________________________________________________________
D.Transportation Information:_______________________________________________________
What type of transportation do you use? (check all that apply) ____private vehicle ____bus
____taxi ____family/friends ____other: please explain: __________________________________
Would any job that you obtain need to be accessible by bus (route and schedule)? ___ yes ___ no Do you have an alternative plan for transportation in case of an emergency? _____ yes ______ no
Describe the alternative plan:_______________________________________________________
Do you have a valid driver’s license? ___ yes ___ no
If no, do you plan to get a driver’s license? ____ yes ____ no
Do you plan to take driver’s education if you do not currently have a driver’s license? __yes ___ no
Do you have a Chauffeur’s or CDL license? ___yes ___ no
E. Monthly Support and Benefits at Application:________________________________________
Have you ever applied for Social Security Disability or Supplemental Security Income? ___yes___no If so, what were the results? ___approved ___denied ___pending ____in appeal process
If you are receiving public support, please enter whole dollar amounts next to the benefit you receive:
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__________SSDI |
__________SSI |
__________TANF __________Veteran’s Disability |
__________General Assistance |
__________Worker’s Compensation |
__________Other Public Support (specify_____________________________________________)
What is your primary source of support? ____ personal income (earnings, interest, etc.)
______Family/Friends |
_____Public Support (SSI, SSDI, TANF, etc) ___All Other Sources |
What source of health insurance do you use? (check all that apply) |
____Current Job |
____Medicaid |
____Medicare ____Public Insurance from Other sources |
____ No Health Insurance |
_____Private (Health Insurance Company:_______________________ |
) |
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F. Reported Criminal Background:____________________________________________________
Do you anticipate problems with a background check? ___yes ___no
Have you ever been convicted of a crime? ___ yes ___ no
If yes, explain:______________________________________________________________
What was the outcome of the conviction (parole, prison time, under age-records sealed, etc)?_______
_________________________________________________________________________________
What is the impact on your vocational choices and are there specific jobs you will not be able to do?
__________________________________________________________________________________
G.Education Information at Application:_______________________________________________
What is the highest grade you completed? _______________
Did you receive special education services while in high school?____yes ____ no
If Yes, when (month/year) did you begin special education services? _______
Did you receive services in high school under a 504 plan? ______yes ______ no
While in high school are you, or did you participate, in a work experience program? ____ yes ____ no Are you planning on pursuing further training? ____ yes ____no (if yes, please describe the program and or school:______________________________________________________________________)
If you have plans to pursue an education beyond high school:
Have you received the Free Application for Federal Student Aid (FAFSA)?___ yes ___ no Have you applied for student financial aid? ___yes ___ no
Are you in default of a federal student loan?____ yes ____ no
Are there any personal problems or circumstances that might interfere with you working while attending school? (If yes, please explain) ____yes ____no Explain:____________________________
__________________________________________________________________________________
Education History:
Name and Location of High School:_____________________________________________________
High School Student ID Number, if currently a high school student in Iowa: _____________________
Month and Year Graduated:_____________________________ (may be a future target date)
…………………………………………………………………………………………………………..
Last College or Vocational Training School Attended:_______________________________________
School Location: ____________________________ Completed Program?____ yes ____no
If you did not complete the program please explain why:_____________________________________
__________________________________________________________________________________
Major or Program:_________________________________Degree/Certificate:___________________
Dates Attended: from____________ to ____________ GPA:____________
…………………………………………………………………………………………………………….
Other College or Vocational Training School Attended:______________________________________
School Location: ____________________________ Completed Program?____ yes ____no
If you did not complete the program please explain why:_____________________________________
__________________________________________________________________________________
Major or Program:_________________________________Degree/Certificate:___________________
Dates Attended: from____________ to ____________ GPA:____________
H. Employment History:_____________________________________________________________
Are you currently employed? ___yes ___ no
Employer:_________________________________ Job Title:_________________________________
Address:___________________________________City:________________State:_______Zip:_____
Wage:_________per _______(hour, week, biweekly, bimonthly, year)
Hours Per Week:___________ Date Began:__________________
Specific Duties:_____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Other Experience:
Have you served in the military? ___yes ___ no
If yes, ____ Honorable discharge ____ Dishonorable Discharge
If Dishonorable Discharge, please explain: _______________________________________________
Have you had jobs other than the one listed above? If so please provide the following information:
Employer:__________________________________ Job Title:_______________________________
Address: ___________________________________City_____________State:__________Zip:_____
Date Began:_______month _______year Date Ended: ________month _________ year
Direct Supervisor: _________________________________________ Phone: ___________________
Specific Duties:_____________________________________________________________________
__________________________________________________________________________________
Reason for Leaving: ___change jobs ___further education ____relocated ____company went out of
business ____laid off (explain:________________________________________________________)
_____fired (explain:________________________________________________________________)
_____other________________________________________________________________________)
Will this employer provide a good reference for you? ___ yes ___ no (if no, what do you think the employer will say?_________________________________________________________________)
………………………………………………………………………………………………………….
Employer:__________________________________ Job Title:_______________________________
Address: ___________________________________City_____________State:__________Zip:_____
Date Began:_______month _______year Date Ended: ________month _________ year
Direct Supervisor: _________________________________________ Phone: ___________________
Specific Duties:_____________________________________________________________________
__________________________________________________________________________________
Reason for Leaving: ___change jobs ___further education ____relocated ____company went out of
business ____laid off (explain:________________________________________________________)
_____fired (explain:________________________________________________________________)
_____other________________________________________________________________________)
Will this employer provide a good reference for you? ___ yes ___ no (if no, what do you think the employer will say?_________________________________________________________________)
………………………………………………………………………………………………………….
Employer:__________________________________ Job Title:_______________________________
Address: ___________________________________City_____________State:__________Zip:_____
Date Began:_______month _______year Date Ended: ________month _________ year
Direct Supervisor: _________________________________________ Phone: ___________________
Specific Duties:_____________________________________________________________________
__________________________________________________________________________________
Reason for Leaving: ___change jobs ___further education ____relocated ____company went out of
business ____laid off (explain:________________________________________________________)
_____fired (explain:________________________________________________________________)
_____other________________________________________________________________________)
Will this employer provide a good reference for you? ___ yes ___ no (if no, what do you think the employer will say?_________________________________________________________________)
…………………………………………………………………………………………………………..
Do you have the documents necessary to comply with Form I-9, Employment Eligibility Verification, which all employers must file for new employees? ___ yes ___ no
