Va Form 28 8872 PDF Details

When veterans embark on the path to rehabilitation and reintegration into civilian life, they are often met with various forms and procedures that facilitate this transition. Among these, the VA Form 28-8872, a comprehensive document designed to establish and outline a detailed rehabilitation plan, stands out for its role in assisting veterans. This form encapsulates important information including the veteran's name, claim number, social security number, and specifics regarding the rehabilitation program such as the type of plan, amendment details, and program goals. Critical to its structure are the outlined objectives to achieve planned goals, providing a clear road map for the rehabilitation process. Each objective is paired with anticipated completion dates, descriptions of the services provided, and the duration of these services, alongside details of the service providers. Moreover, the form includes mechanisms for evaluating progress through predefined criteria, procedures, and schedules. Signing this form signifies a veteran’s commitment to actively participate and cooperate in the rehabilitation program, understanding the importance of periodic reviews. The form also stresses privacy and confidentiality in handling veterans' information, ensuring compliance with the Privacy Act of 1974. This multifaceted document thus plays a pivotal role in structuring the rehabilitation journey of veterans, setting clear expectations, and providing a structured framework for achieving their rehabilitation goals.

QuestionAnswer
Form NameVa Form 28 8872
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva 8872 prevention of workplace harassment no fear, va form plan, 28 8872, 28 form va 8872

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REHABILITATION PLAN

1. DATE

 

2. FIRST - MIDDLE - LAST NAME OF VETERAN

3. CLAIM NUMBER

4. SOCIAL SECURITY NUMBER

 

C-

 

5. PROGRAM PLAN

 

 

6A. TYPE OF PLAN

6B. AMENDMENT NO. TO IWRP

6C. DATE OF IWRP

7. PROGRAM GOAL

NOTE: INTERMEDIATE OBJECTIVES TO ACHIEVE PLANNED GOAL COVERED IN ITEMS 8 THRU 11.

8A. OBJECTIVE ONE (Description)

 

8B. ANTICIPATED COMPLETION DATE

 

 

 

 

8C. SERVICES PROVIDED

 

8D. DURATION OF SERVICES

 

 

FROM (Mo., Yr.)

 

TO (Mo., Yr.)

 

 

 

 

 

8E. NAME & ADDRESS OF PERSON OR INSTITUTION PROVIDING SERVICES

8F. PERSON TO CONTACT (If institution)

 

 

 

 

 

8G. TELEPHONE NO. (Include Area Code)

 

 

 

 

 

 

8H. EVALUATION CRITERIA

 

 

 

 

 

 

 

 

 

8I. EVALUATION PROCEDURE

 

 

 

 

 

 

 

 

 

8J. EVALUATION SCHEDULE

 

 

 

 

 

 

 

 

 

8K. PROGRESS NOTES

 

 

 

 

 

 

 

9A. OBJECTIVE TWO (Description)

 

9B. ANTICIPATED COMPLETION DATE

 

 

 

9C. SERVICES PROVIDED

 

9D. DURATION OF SERVICES

 

 

FROM (Mo., Yr.)

 

TO (Mo., Yr.)

 

 

 

 

 

9E. NAME & ADDRESS OF PERSON OR INSTITUTION PROVIDING SERVICES

9F. PERSON TO CONTACT (If institution)

 

 

 

 

 

9G. TELEPHONE NO. (Include Area Code)

 

 

 

 

 

 

9H. EVALUATION CRITERIA

 

 

 

 

VA FORM

28-8872

SUPERSEDES VA FORM 28-8872, SEP 1989, WHICH

JUL 2010

WILL NOT BE USED.

Continued on Reverse

ITEM 9 (CONTINUED)

 

 

 

 

9I. EVALUATION PROCEDURE

 

 

 

 

 

 

 

 

 

9J. EVALUATION SCHEDULE

 

 

 

 

 

 

 

 

 

9K. PROGRESS NOTES

 

 

 

 

 

 

 

 

10A. OBJECTIVE THREE (Description)

 

10B. ANTICIPATED COMPLETION DATE

 

 

 

 

10C. SERVICES PROVIDED

 

10D. DURATION OF SERVICES

 

 

FROM (Mo., Yr.)

 

TO (Mo., Yr.)

 

 

 

 

 

10E. NAME & ADDRESS OF PERSON OR INSTITUTION PROVIDING SERVICES

10F. PERSON TO CONTACT (If institution)

 

 

 

 

 

10G. TELEPHONE NO. (Include Area Code)

 

 

 

 

 

 

10H. EVALUATION CRITERIA

 

 

 

 

 

 

 

 

 

10I. EVALUATION PROCEDURE

 

 

 

 

 

 

 

 

 

10J. EVALUATION SCHEDULE

 

 

 

 

 

 

 

 

 

10K. PROGRESS NOTES

 

 

 

 

 

 

 

 

 

11. CLOSURE STATEMENT

 

 

 

 

I CERTIFY THAT I have participated in the development of this program plan. I understand it is my responsibility to cooperate in the program and make reasonable efforts on my behalf. There will be periodic and/or an annual review of the plan, at which time the VA staff members and I will have a chance to jointly redevelop it.

12. SIGNATURE OF VETERAN

13. SIGNATURE OF COUNSELING PSYCHOLOGIST

 

 

14. SIGNATURE OF VOCATIONAL REHABILITATION SPECIALIST

15. ANNUAL REVIEW DATE

 

 

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for the purpose of educational and vocational planning and to help you make the best use of your rehabilitation benefits. This information will not be released outside VA unless you authorize its release in writing or the disclosure is authorized under the Privacy Act, including the routine use identified in VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.

VA FORM 28-8872, JUL 2010

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va form plan gaps to fill in

Provide the appropriate data in the field H EVALUATION CRITERIA, I EVALUATION PROCEDURE, J EVALUATION SCHEDULE, K PROGRESS NOTES, A OBJECTIVE TWO Description, B ANTICIPATED COMPLETION DATE, C SERVICES PROVIDED, D DURATION OF SERVICES TO Mo Yr, FROM Mo Yr, E NAME ADDRESS OF PERSON OR, F PERSON TO CONTACT If institution, G TELEPHONE NO Include Area Code, and H EVALUATION CRITERIA.

va form plan H EVALUATION CRITERIA, I EVALUATION PROCEDURE, J EVALUATION SCHEDULE, K PROGRESS NOTES, A OBJECTIVE TWO Description, B ANTICIPATED COMPLETION DATE, C SERVICES PROVIDED, D DURATION OF SERVICES TO Mo Yr, FROM Mo Yr, E NAME  ADDRESS OF PERSON OR, F PERSON TO CONTACT If institution, G TELEPHONE NO Include Area Code, and H EVALUATION CRITERIA fields to insert

Put together the crucial information in the ITEM CONTINUED, I EVALUATION PROCEDURE, J EVALUATION SCHEDULE, K PROGRESS NOTES, A OBJECTIVE THREE Description, B ANTICIPATED COMPLETION DATE, C SERVICES PROVIDED, D DURATION OF SERVICES TO Mo Yr, FROM Mo Yr, E NAME ADDRESS OF PERSON OR, F PERSON TO CONTACT If institution, G TELEPHONE NO Include Area Code, and H EVALUATION CRITERIA segment.

part 3 to finishing va form plan

You will have to describe the rights and obligations of both sides in paragraph I EVALUATION PROCEDURE, J EVALUATION SCHEDULE, K PROGRESS NOTES, CLOSURE STATEMENT, I CERTIFY THAT I have participated, SIGNATURE OF VETERAN, SIGNATURE OF COUNSELING, SIGNATURE OF VOCATIONAL, and ANNUAL REVIEW DATE.

Completing va form plan stage 4

Look at the fields PRIVACY ACT NOTICE VA will not, and VA FORM JUL and thereafter fill them in.

va form plan PRIVACY ACT NOTICE VA will not, and VA FORM  JUL blanks to fill out

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