DHS 1277 Service Questionnaire (Vocational Rehabilitation ...Page 1 of 10 DHS 1277 (10/2016) Service...

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Service Questionnaire

If you need help filling out this form please call the Vocational Rehabilitation office before your first appointment. We can help! You can get this document in other languages, large print, braille or a format you prefer. Contact Vocational Rehabilitation at 503-945-5880 or email [email protected]. We accept all relay calls.

Personal information Last name:

First name:

Middle name:

Preferred name and pronouns:

Previous name(s):

Birthdate:

Email address:

Gender:

Social Security number: - -

Phone number: Cell Landline VP (video phone) Fax

Second phone number: Cell Landline VP (video phone) Fax

Home address:

Lived there since:

City:

State:

County:

ZIP code:

Mailing address (if different than above home address): City:

State:

ZIP code:

Racial and ethnic background (check all that apply): How do you identify your race, ethnicity, tribal affiliation, country of origin or ancestry? Which of the following describe your racial or ethnic identity? (Check all that apply)

American Indian or Alaska Native Alaska Native American Indian Canadian Inuit, Metis, or First Nation Indigenous Mexican, Central American, or South American

Middle Eastern/Northern African Middle Eastern Northern African

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Asian Asian Indian Chinese Filipino/a Hmong Japanese Korean Laotian South Asian Vietnamese Other Asian

Black or African American African (Black) African American Caribbean (Black) Other Black

Hispanic or Latino/a Hispanic or Latino/a Central American Hispanic or Latino/a South American Hispanic or Latino/a Mexican

Native Hawaiian or Pacific Islander Guamanian or Chamorro Native Hawaiian Samoan Other Pacific Islander

White Eastern European Other White Slavic Western European

Other Categories Other (please list): Don’t know/Unknown

Are you an enrolled member of a federally recognized Tribe?

Tribal ID: CIB:

Tribal affiliation:

Don't want to answer/Decline

Preferred language: What language do you want us to use with you? Speaking: English Spanish ASL Other:

Writing: English Spanish Other:

Do you need an interpreter for us to communicate with you?

No Don’t know/Unknown Don’t want to answer/Decline Yes, sign language. What kind? (ASL, PSE, ProTactile, etc.) Yes, spoken language. Which language?

If there is a bilingual VR Counselor* available, do you want to be assigned to their caseload?

Yes No *Bilingual staff have passed a formal language proficiency test

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How well do you speak English? Very well Well Not well Not at all Don’t know/Unknown Don’t want to answer/Decline

Have you been a VR client before? Yes No

If yes, where (city/state) and when (year)?

Are you a U.S. citizen? Yes No

If no, do you have documents that show you can legally work in the United States?

Yes No

Emergency contact(s) (Optional): Name:

Relationship:

Phone or email:

Name:

Relationship:

Phone or email:

Your living arrangement

Private home or apartment (you pay rent or mortgage with or without housemates)

Live with parents (in their home) Community residential or group home

Inpatient drug/alcohol treatment Halfway house

Dorm or school-based housing Homeless or in a shelter

Other

Marital status: Never Separated

Married Widowed

Divorced Domestic partnership

Household members (do not include roommates you split costs with) I live alone Self and partner or spouse Parents

Children under 18 How many? How old are they?

Who referred you to VR? (Name of person or organization)

What is their email or phone number?

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Your income How do you currently support yourself? Amount:

Supplemental Security Income (age 16–64) (SSI): Social Security Disability Income (SSDI):

Supplemental Security Income (age 65+) (SSI): Temporary Assistance for Needy Families (TANF):

Supplemental Nutrition Assistance Program (SNAP): Unemployment Insurance (UI):

Workers’ Compensation Time Loss: Veterans’ benefits:

Income from spouse, partner or family members’ job(s): Income from my job:

Other (specify):

Total: Do you have a court appointed legal guardian? No Yes

If yes, what is their name and phone number and/or email? (Please bring court papers to your first meeting with VR)

Do you have a representative payee? No Yes

If yes, what is their name and phone number or email?

Medical insurance information Check all that apply: None

OHP (Oregon Health Plan) Private insurance through my job OHP Plus Not yet eligible for insurance from my job ACA Exchange Private insurance (other sources) Medicare Public insurance (other sources) Medicaid Workers’ Compensation

Insurance company and ID number(s):

Medicare/Medicaid number:

OHP Plan and ID number:

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Education information High school School(s) you attended City and state When (years) Did you graduate from high school?

No What is the highest grade you completed?

Yes When? (month and year)

Standard Diploma Modified Diploma

Certificate of Completion/Attendance

GED

Were you in special education classes? Yes No

Did you have an IEP (Individualized Education Program)? Yes No

Did you have a 504 Plan? Yes No

Were or are you a participant in a Youth Transition Program (YTP)? Yes No

District and school name: City and state:

College; university; or military, technical or trade training school School name Start date End date Degree or certification

Are you currently attending college or an apprenticeship? Yes No If yes, where (name of school)? Are you currently in default on any federal student loans? Yes No

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Employment information

Are you working now? Yes No Last month and year that you worked:

Salary or hourly wage: $ Hours per week:

Work history (please list your most recent job first) Employer 1:

Job title:

Location (city and state): Full time Part time

Job duties:

Did your disability cause you problems at work? Yes No

If yes, how?

Start date: End date: Last salary/pay rate:

Reason for leaving: Fired Laid off Quit Moved or relocated

Other (please explain): Employer 2:

Job title:


Job duties:


If yes, how?


Reason for leaving: Fired Laid off Quit Moved or relocated Other (please explain):

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Employer 3:

Job title:


Job duties:


If yes, how?



Unpaid, volunteer or internship experiences Volunteer or internship position 1:

Organization or site:

Location (city, state): Full time Part time

Duties:

Did your disability cause you problems here? Yes No

If yes, how?



Volunteer or internship position 2:

Organization or site:

Location (city, state): Full time Part time

Duties:

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Did your disability cause you problems here? Yes No

If yes, how?



Do you need VR to help keep your job? Yes No Are you a migrant or seasonal farmworker? Yes No Are you a veteran? Yes No Were you injured during your military service? Yes No Are you working with a mental health program? Yes No Are you part of the Lane v. Brown class action? Yes No

Disability information Please list your health conditions, disabilities or diagnoses (physical, mental or emotional). List them in order putting the most severe/hardest to deal with FIRST.

Condition or diagnosis

Year of onset/when started: How it affects me:

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Please list any medications or supplements that you are currently taking for any of the conditions listed above (you can add a page with your list on it if that is easier): Medication or supplement Purpose Information about your doctors and providers

Name Address Phone Reason you see this person

Special programs (check all that you are involved with)

None Tribal Vocational Rehabilitation

Aging and People with Disabilities (APD)

Intellectual and Developmental Disability Services: Support services brokerage

Independent Living Center (IL) State Developmental Disabilities Services: Other programs

Developmental Disability Services: County case management Oregon State Hospital (OSH)

Oregon Commission for the Blind (OCB) Preferred Worker Program/Workers Compensation

Oregon Youth Authority (OYA) Supplemental Nutrition Assistance Program (SNAP)

Stabilization and Crisis Unit (SACU) Temporary Assistance for Needy Families (TANF)

Supported mental health (OSECE) WorkSource

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Other places you get support or help Please list any contacts at the other agencies and organizations you are currently involved with. Name of agency Contact person Phone number and email

Your goals What services do you think you might need from Vocational Rehabilitation to be successful at getting a job or keeping your current one? (Check all that apply)

Help picking a job goal Learn how to look for work and interview Help with medical equipment Learn how to work with my disability

Other (please explain): What are your strengths and skills?

What type(s) of work are you interested in doing?

How many hours a week do you want or need to work? Full time Part time hours per week: Not sure

How do you get around? Bus Car Bike Other Do you have a valid driver’s license? Yes No State: Do you have valid insurance? Yes No Do you have a clean driving record? Yes No If no, please explain:

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Have you ever been arrested or convicted of a crime (felony or misdemeanor)? Yes No

If yes, please explain:

Is there anything else we should know about you and your goals?

Thank you for taking the time to answer these questions. This information will help us make your services better.

Please bring this to the appointment with your VR Counselor!

DHS 1277 Service Questionnaire (Vocational Rehabilitation ...Page 1 of 10 DHS 1277 (10/2016) Service...

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