Fill a Valid Iowa R 412 Template

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:

__________Other Public Support (specify_____________________________________________)

What is your primary source of support? ____ personal income (earnings, interest, etc.)

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:_____________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________