1. Explain the information being requested on the Application form to the individual and review the "Information for You" section of the form with the person. Make sure each of the areas are covered in a way that assures the applicant (and his or her parent, guardian, or representative) understands the information.
2. Complete the Application form.

• If the applicant is not a United States born citizen, view his/her original USCIS document(s) and  scan a copy of the front and back of the presented document(s), the front and back of the  Employment Authorization Card (I-766) if there is one, and the front of the social security card if there is one for the case file. If the applicant cannot produce his/her immigration document the application cannot be accepted. Note: Except for non-citizens, staff are not to make copies of any documents an individual would use in completing an I-9 form.
• Enter the required information in the Citizenship section of QE2  Basic Info Screen. Here is a sample of immigration documents.
• Scan and email the copies of the presented immigration document(s), I-766 if there is one, and the copy of the Social Security Card to the VR HR Program Director.
• All non-citizens will have his/her lawful presence and/or lawful authorization to work verified through the DHS-USCIS Systematic Alien Verification for Entitlements (SAVE) Program by VR State Office. State Office will notify the Team Contact of the results of the verification.
• The VR eligibility decision cannot be made nor assessment services provided until both his/her lawful presence and authorization for employment is verified.
• Applicants who are not verified as being lawfully present in the United States and/or do not have authorization to work will be terminated from the Applied for VR milestone as a VR Termination, “Other reason”. The task note should indicate the applicant is either not lawfully present and/or not authorized to work.

3. Complete a Release of Information form and for an applicant who is an SSDI or SSI recipient based on their disability, complete the SSA 3288 Consent for Release of Information/Earnings (VR) and the SSA 3288 Consent for Release of Information/General (VR).

4. If the applicant answered "yes" or "not sure" to the ABI pre-screening question on the application, complete the Nebraska VR ABI Screen with the applicant. If the applicant answered "no" to the ABI question on the application, no further action is required. (also see the Employment Discussion Chapter)

5. Enter all of the information from the completed Application form into QE2 and transfer the referral into the Employment Program.

• Informing prospective applicants. To assure voluntary informed choice, prospective applicants first must be provided with an Employment Discussion. This should be done at the first appointment,.
• Required for transfer to the Employment Program. Before an individual in the Information and Referral milestone can be transferred to the Employment Program, he or she (or his or her parent, or legally appointed guardian or representative) must sign a completed VR application form.
• Minors. If the person is a minor, his or her parent, or legally appointed guardian or representative must sign the application. A minor is anyone under the age of 19, except for individuals who are married. 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.
• Lawful presence in the United States. Nebraska statute requires that state agencies providing services deemed as a public benefit are required to verify the lawful presence of any applicant for services who attests to not being a United States citizen.
• Lawfully authorized to work. It is the policy of the agency to only serve those non-citizen applicants for services who are authorized to work by the United States Citizenship and Immigration Services (USCIS).
• Effective date of application. The effective date of the application is the date an application is received by Nebraska VR that has been signed by the person (or the person's parent, or legally appointed guardian or representative if he or she is a minor or legally incompetent). The VR Representative receiving the completed application shall acknowledge receipt by signing the application and dating the signature with the date and time the application was received.

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. A 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.

Refusal to answer

Record as "No."

Race

This is the self-reported race of the person. He or she 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 his/her 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 his/her 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 his/her 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 his/her race or races using the terms "American Indian" or "Alaska Native" or by stating his/her 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 his/her 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.

Refusal to answer

Record as "White."

Social Security and other cash benefits

These are benefits paid to the applicant because of his or her 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 they receive, Worker's Compensation benefit, TANF or other public support benefits they receive.

Medical/Health Insurance

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

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

U.S. citizen

Please see the Process Section above for specific information on regarding non U.S born citizens.

Veteran

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

Marital Status

Please identify the marital status of the individual.

Level of education

This is the highest academic credential held by the person. A person who has graduated from high school and has completed 2 years at a university has a "high school diploma."

• No formal schooling
• Elementary education (1-8)
• No high school diploma or GED (9-12)
• Special education certificate of completion/diploma
• High school graduate or GED
• Post-secondary education, no degree or certificate
• Post-secondary academic degree, Associate degree
• Bachelor's degree
• Master's degree
• Any degree above a Master's degree
• Occupational credential beyond undergrad
• Occupational credential beyond graduation
• Vocational/Technical certificate or license (CNA, Apprenticeship, etc.)

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 is the first step in identifying applicants with potentially undiagnosed ABI.

What is your present employment status?

The purpose of this item is to identify the activity that best describes the employment status of the applicant.

Employment Choices for job held at application:

• Employed: But Losing Job/Transitioning Sevice Member
• Employed: Competitive Integrated
• Employed: Extended Employment (Sheltered Workshop)
• Employment: Self Employment
• Not Employed: All other students
• Not Employed: Student in High School
• Not Employed: Trainee, Intern or Volunteer
• Not Employed: Other

If the Applicant is working at application, collect the following information and enter on the Employment History Screen. At the time of IPE Approval you will be asked to review this information and change if the job the client has at IPE is different than the job at application.

• Who did you work for? Record the employer's business name.
• What is your job? Record job title. Describe work performed in enough detail to find the SOC code.
• How much do you earn in a typical week? If the person is paid weekly, bi-weekly, bi-monthly, or monthly, record earnings, how often the person is paid, and type of pay period. If the individual receives tips on their job include the tips in their earnings.
• How many hours do you work? Record the number of hours worked in a typical week. If the person's hours vary significantly week to week, or if he or she is paid bi-weekly, bi-monthly, or monthly, record the average number of hours worked per week.
• Date started job. Record the date the person started working on his or her current job.
• Benefits available. Check each benefit available to the person on the job, regardless of whether he or she is using it. For example, if health insurance is available to workers on the job, check it as available, even if the person is not signed up for it.

Physical or mental impairments limiting ability to work

Record the health or medical conditions, injuries, or physical and mental impairments the person identifies as limiting his or her ability to work. Limitations include restrictions placed on the person's work activities by physicians and other health professionals. Identify the physical or mental impairment in sufficient detail to be able to identify the impairment and its cause in QE2.

Kind of job wanted

Record the kind of job the person says he or she wants to do, regardless of whether this appears reasonable. If the person is unsure or has no job expectations, record that answer.

Help needed to go to work

Record the kind of help the person says he or she needs, regardless of whether this appears reasonable. If the person is unsure or has no awareness of service needs, record that answer.

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?

If the person answers yes, refer them to the web site listed on the application form or set them up on a community computer in the office so they can go online and register to vote.

Living Situation

Record the living situation of the person at the time of application.

• Private Residence
• Community Residential/Group Home
• Rehab Facility
• Mental Health Facility
• Nursing Home
• Adult Correctional Facility
• Halfway House
• Substance Abuse Treatment Center
• Homeless/Shelter
• Other

Primary Source of Support

Mark the appropriate primary source of support for the applicant. Applicant must also fill out the Sources and Services document that is attached to the Application. The Sources and Services documents specific information regarding their Primary Source of Support and Primary Source of Services. Primary Source of Support detail information is entered on the Household Income Screen. Information from the Primary Source of Services is entered on the Services and Benefits Screen (IPE tab).

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

Referral source

Record who told the person to get in touch with 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 he or she was referred.

Signatures

• Applicant. The applicant must sign the application, unless he or she is a minor or legally incompetent. However, it is good practice to always have the applicant sign.
• Parent, Guardian, or Representative. If the applicant is a minor or legally incompetent, a parent, guardian, or other legally appointed representative must sign the Application.
• VR Representative. Any VR staff member may sign the Application.

Application - English

Career Planning Preferences - English

Application - Spanish

Release of Information English

INACTIVE FORM: BP/SSA 3288 Consent for Release of Information - Earnings Eng/Spanish

INACTIVE FORM: VR/SSA 3288 Consent for Release of Information - General English/Spanish

Emancipated Minor Form

Nebraska VR ABI Interview

INACTIVE FORM: Nebraska Brain Injury Information, Referral and Resource Facilitation Services Brochure