Va Form 28 8872 PDF Details

The Va Form 28 8872 is a document used to apply for disability compensation. This form can be tricky to fill out, so it is important to understand the instructions and how to complete it correctly. In this blog post, we will go over the basics of the Va Form 28 8872 and provide tips on how to submit a strong application.

This page has got information about va form 28 8872. It can be useful to know its size, the actual time to prepare the form, the fields you will need to fill in, and so on.

QuestionAnswer
Form NameVa Form 28 8872
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names28 8872, va form 28 8872, 28 form va 8872, 8h 28 8872 form

Form Preview Example

 

 

 

 

 

 

 

 

 

 

REHABILITATION PLAN

 

 

1. DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. FIRST - MIDDLE - LAST NAME OF VETERAN

 

 

3. CLAIM NUMBER

 

4. SOCIAL SECURITY NUMBER

 

 

 

 

C-

 

 

 

 

5. PROGRAM PLAN (Check one)

 

 

6A. TYPE OF PLAN

 

 

 

IEEP - INDIVIDUALIZED

IWRP - INDIVIDUALIZED

ORIGINAL

AMENDMENT

(If "Amendment," complete

Items 6B and 6C)

 

EXTENDED EVALUATION

WRITTEN REHABILITATION

 

 

 

 

6B. AMENDMENT NO. TO IWRP

 

6C. DATE OF IWRP

 

 

 

 

 

 

 

IEAP - INDIVIDUALIZED

IILP - INDIVIDUALIZED

 

 

 

 

 

EMPLOYMENT ASSISTANCE

INDEPENDENT LIVING

 

 

 

 

 

 

 

 

 

 

 

 

 

7. PROGRAM GOAL

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: INTERMEDIATE OBJECTIVES TO ACHIEVE PLANNED GOAL COVERED IN ITEMS 8 THRU 12.

 

 

8A. OBJECTIVE ONE (Description)

 

 

 

 

8B. ANTICIPATED COMPLETION DATE

 

 

 

 

 

 

 

 

8C. SERVICES PROVIDED

 

 

 

 

 

8D. DURATION OF SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM (Mo., Yr.)

TO (No., 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 (No., 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEP 1989

28-8872

 

WILL BE USED.

 

 

 

 

 

VA FORM

 

EXISTING STOCKS OF VA FORM 28-8872, MAR 1981,

 

CONTINUED ON

ITEM 9, CONTINUED

9I. EVALUATION PROCEDURE

9J. EVALUATION SCHEDULE

9K. PROGRESS NOTES

10A. OBJECTIVE THREE (Description)

10C. SERVICES PROVIDED

10B. ANTICIPATED COMPLETION DATE

10D. DURATION OF SERVICES

FROM (Mo., Yr.)

TO (No., 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. CONTINUATION SHEET

CHECK BOX IF VA FORM 28-8872A, REHABILITATION PLAN - CONTINUATION SHEET, IS USED

12. 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.

13. SIGNATURE OF VETERAN

14. SIGNATURE OF COUNSELING PSYCHOLOGIST

15. SIGNATURE OF VOCATIONAL REHABILITATION SPECIALIST

16. ANNUAL REVIEW DATE

Watch Va Form 28 8872 Video Instruction

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