Required forms:  Forms must be completed with appropriate signatures to apply for vocational rehabilitation services. 

• VR Application, 
• VR Release, and
• Summary of Initial Meeting or Next Action
• Other releases and screens, as applicable:
  • ABI (Acquired Brain Injury) pre-screening question: If the applicant answered "yes" or "not sure" to this question on the application, screen the applicant for their lifetime history of possible ABI incidents using the Nebraska VR ABI Interview Form. 
  • SSI/SSDI recipient based on their disability: complete and have applicant sign SSA 3288 Consent for Release of Information/General (VR) form if the applicant receives SSI or SSDI based on a disability.

Lawful presence in the United States: Nebraska statute §§ 4-108 through 4-114 requires that every agency shall verify the lawful presence in the United States of any person who has applied for public benefits administered by an agency or political subdivision of the State of Nebraska. This section shall be enforced without regard to race, religion, gender, ethnicity, or national origin. Verification: Nebraska VR must inform all applicants that individuals who receive services must intend to work and attest to their lawful presence in the United States. By signing the application, the individual is attesting to their Lawful Presence in the U.S. and intent to work. No other verification is needed.

Lawfully authorized to work: It is the policy of the agency to only serve applicants for services who are authorized to work. This is for all individuals, citizens, and non-citizens alike.  This verification is consistent with the I-9 and will be required to be verified in QE2 prior to IPE approval or participation in a Trial Work Experience, OJE, or WBLE. These documents can be verified and documented in QE2 any time prior to IPE approval or participating TWE, OJE, or WBLE. 

Effective date of application: The VR Representative receiving the completed application with the required signatures, shall acknowledge receipt by signing and dating the VR signature box with the date and time the application was received. The VR representative signature is the final signature and effective date of the application. See Program Manual Signatures Required on VR Documents

Open Case in Two States: If you learn a case is open with another state VR agency or if the individual tells you they are going to apply for services from another state VR agency, contact the Program Director for Counseling Services to discuss the situation and determine the appropriateness of opening a Nebraska case. Since both state VR programs offer the same services, there is a likelihood for duplication of services. If determine necessary, an individual may have an active case in two state VR agencies at the same time and both VR agencies would be allowed to record a successful employment outcome.

Offer applicant a copy of completed documents.

Voter Registration: This opportunity must be offered at the time an individual:

• Applies for services 
• Participates in an annual review 
• Notifies VR of an address change

Follow the steps outlined in the Program Manual Chapter: Assisting Individuals with Disabilities to Register to Vote.

1. Informed Choice: Prospective applicants must be provided a VR Orientation and Initial Meeting to determine if they would like to apply and participate in VR services. Nebraska VR staff are responsible to provide an Orientation which includes Nebraska VR is an employment program which requires individuals who receive services intend to work. See Program Manual Chapter: Initial Meeting
2. Required Forms: All individuals completing the VR Application are also required to complete a VR Release form. A case cannot proceed without both documents, as a signed release is needed to obtain medical information, coordinate services, contact employers, etc. In turn, the VR Release alone is not valid without the VR Application, as the release only pertains to VR applicants or recipients of VR Services. All forms must be completed with appropriate signatures to apply for vocational rehabilitation services. See Program Manual Chapter: Signature Requirements on VR Documents
   • VR Application: Ensure all areas of the application are covered in a way that assures the applicant and authorized representative, as applicable, understands the information. Explain the information being requested on the application form to the individual to include the Terms and Conditions section on the back. Review the narrative section above the signature box, ensure the applicant understands their signature on the application verifies their intent to achieve an employment outcome and attests to their lawful presence in the United States. The individual's signature on the application is sufficient evidence and no further information is required.
   • VR Release: Ensure appropriate signatures are gathered for a valid release. Discuss why the form is required and what information is shared. This form allows VR to gather medical information, obtain existing career planning information, coordinate services with other organizations, and exchange information with employers and other entities on the individual's behalf. 
   • Summary of Initial Meeting or Next Action: Complete either form to provide a written summary of the meeting and a provide a copy to the applicant a copy for reference to ensure the individual understands the next steps in the process.  
   • Other releases and screens, as applicable:
     • SSDI or SSI recipient based on their disability: 
       • SSA 3288 Consent for Release of Information/General (VR) with appropriate signatures. See Program Manual Chapter: Eligibility Social Security Recipients
     • ABI (Acquired Brain Injury) pre-screening question: 
       • If the applicant answered "yes" or "not sure" to this question on the application, screen the applicant for their lifetime history of possible ABI incidents using the Nebraska VR ABI Interview Form at the time of application or during the Initial Meeting. Download an age- and region-specific brochure listing ABI resources to give to the applicant at: https://braininjury.nebraska.gov/brain-injury-registry-brochures-2021
       • If the applicant answered "no" to the ABI pre-screening question on the application, no further action is required. See the Initial Meeting Chapter for more instruction on this process.
3. Authorized to Work/Employment Eligibility Verification:  The VR Application can be completed without verification of authorization to work/employment documents, but this will be required prior to IPE approval or participation in Work Based Learning Experience (WBLE), On-the-Job Evaluation (OJE), or a Trial Work Experience (TWE). Both citizens and non-citizens alike must have their work documents verified by VR, but it is optional to save and upload them to QE2 as a work verification document. VR can assist financially with obtaining these documents, if needed after VR eligibility has been completed (QE2: Career Planning-Other Assistance) or when a TWE (QE2: Eligibility-Other Assistance) is needed. See the Individualized Plan for Employment Chapter for more information.

• Citizens:  View and verify work documents specified in the I-9 form. Examples of work documents: acceptable work documents
•  Non-citizens: Immigration documents showing authorized to work by the United States Citizenship and Immigration Services (USCIS). Sample of immigration documents. 
• All non-citizens will have their lawful authorization to work verified through the USCIS Systematic Alien Verification for Entitlements (SAVE) Program by Assistant Director.
• Enter the required information in the Work Document Verification section of QE2 Basic Info Screen.
• View and scan a copy of the front and back of the original immigration document(s) and email the copy of the presented immigration document(s) to the VR Assistant Director.
• The Team Contact will be notified of the results of the verification and will enter them into a QE2 task note.​​​​​​

4. Process for Emancipated Minor: For an individual under 19 years of age who is living completely separate (physically and financially) from any parents and/or legally responsible adults, follow the procedure for obtaining a waiver of parent signature and completion of the Emancipated Minor Form. 
5. Voter Registration. If the individual indicates they would like to register or re-register to vote follow the steps outlined in the Program Manual Chapter: Assisting Individuals with Disabilities to Register to Vote. 
6. Offer applicant a copy of documents completed.
7. Complete data entry and Initial Meeting documentation. Enter all of the information from the completed Application form into QE2 

Application Information:

Name and address

Use the person's legal name. Do not use diminutives or nicknames. If in doubt, use the name that appears on the person's Social Security card. For non-citizens, enter the name as it appears on his/her immigration document. An address must be gathered for the person, if they are homeless record the address of where they receive mail.

Hispanic or Latino

This is the self-reported ethnicity of the person. Persons who regard themselves as Hispanic or Latino should check "Yes." Hispanics or Latinos can be of any race. For example, many Hispanics coming to Nebraska from Mexico are Native American. Some coming from Puerto Rico, Cuba, the Dominican Republic, and other Caribbean nations are Black.

If refuse to answer, record as "No."

Race

This is the self-reported race of the person. They can check all boxes that apply. Multiple responses are permitted.

• White refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who describe their race or races as "White" or use other terms such as Irish, German, Italian, Lebanese, Near Easterner, Arab, or Polish.
• Black or African American refers to people having origins in any of the Black racial groups of Africa. It includes people who describe their race or races as "Black, African American, or Negro," or use other terms such as African American, Afro American, Nigerian, or Haitian.
• Asian refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. It includes people who describe their race or races as "Asian Indian," "Chinese," "Filipino," "Korean," "Japanese," "Vietnamese," or "Other Asian," or use other terms such as Burmese, Hmong, Pakistani, or Thai.
• Native American or Alaska Native refers to people having origins in any of the original peoples of North, Central, and South America, and who maintain tribal affiliation or community attachment. It includes people who describe their race or races using the terms "American Indian" or "Alaska Native" or by stating their principal or enrolled tribe, such as Santee Sioux, Chippewa, Omaha, or Inuit.
• Pacific Islander or Native Hawaiian refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who describe their race or races as "Native Hawaiian," "Guamanian or Chamorro," "Samoan," or "Other Pacific Islander," or use other terms such as Tahitian, Mariana Islander, or Chuukese.
• "Refused" is an option for those who do not fit the above categories or do not wish to identify.

U.S. citizen

 Non-citizen for specific information on regarding non-U.S born citizens. See Process section above. 

Marital Status

Please identify the marital status of the individual.

Physical or mental impairments limiting ability to work

Record the permanent medical conditions the person identifies as limiting their ability to work. Limitations include restrictions placed on the person's work activities by physicians and other health professionals. Identify the physical, mental, emotional and/or learning impairment(s) in sufficient detail to be able to identify the impairment and its cause in QE2. If there are several impairments to document, best practice would be to number them by the individual's identified severity of the impediment to employment, as this will assist you in determining the primary impairment for eligibility. 

Kind of job wanted

Record the kind of job(s) the applicant states an interest in, regardless of whether this appears reasonable. If the applicant is unsure or has no job expectations, record that answer.

Help needed to go to work

Record the kind of help the applicant is requesting, regardless of whether this appears reasonable. If the individual is unsure or has no awareness of service needs, record that answer.

Medical/Health Insurance

Record the type of medical or health insurance the individual is covered by.

• Affordable Health Care Act
• Medicaid
• Medicare 
• Not yet eligible for private insurance through current employer but will be
• Private insurance through other means (Parent/Family's insurance)
• Private Insurance through own employer
• Public Insurance from other sources (Worker's Comp, Children's Health Insurance Program, etc.
• None

Veteran

Please indicate if the individual served in the active military, naval or air service and was discharged or released under conditions other than dishonorable. 

Primary Source of Support

Mark the appropriate primary source of support for the applicant.

• Personal Income
• Family and Friends
• Public Support
• All Other Sources

Social Security and other cash benefits

These are benefits paid to the applicant because of their disability (Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI)). Social security benefits received for reasons other than the individual's disability (retirement, widower's, etc.) would not be coded as SSDI or SSI in QE2. Also record any Veteran's Disability Benefits, Worker's Compensation benefit, TANF or other public support benefits they receive.

ABI pre-screening question

Identification of potential undiagnosed or “hidden” acquired brain injury (ABI) is important because long-term cognitive, physical, emotional, or behavioral results can present significant barriers to employment and community integration. The ABI pre-screening question on the application is the first step in identifying applicants with potentially undiagnosed ABI, and as appropriate, should be followed by an interview to obtain a lifetime history of possible incidents that may have resulted in ABI. 

If the Applicant is working at application, the employment information must be entered into the work history section of QE2. 

High School Students

If the person is in high school indicate if they have a 504 Plan or IEP.

Do you wish to register to vote?

Nebraska VR must provide the opportunity to individuals with a disability to register to vote. 

Follow the steps outlined in the Program Manual Chapter: Assisting Individuals with Disabilities to Register to Vote.

Referral source

Record who told the individual to contact VR in sufficient detail to be able to accurately identify the Referral Source Category and Referral Source Name in QE2. Most people hear about VR or are told to go to VR by someone working for or associated with an organization. It may take some effort to clarify how the person heard about VR or from which organization they were referred.

Signatures

• Applicant. The individual applying for services must sign the VR Application and Release forms. If the individual has difficulty signing their name a mark on the form is adequate, as this shows agreement and ownership in the process. 
•  Authorized Representative. If the applicant has a legal authorized representative, the appropriate authorized representative must also sign the Application and Release. 
• VR Representative. Any VR staff member may sign the Application. The VR Representative receiving the completed application with the required signatures, shall acknowledge receipt by signing the application and dating the signature with the date and time the application was received. The VR representative signature is the final signature and effective date of the application.

Application - English

Application - Spanish

Release of Information English

Emancipated Minor Form

Nebraska VR ABI Interview

Release of Information Spanish

VR/SSA 3288 Consent for Release of Information - General English

VR/SSA 3288 Consent for Release of Information - General Spanish