1. To assure voluntary informed choice, prospective applicants first must be provided with a VR Orientation and Initial Meeting.
2. Explain the information being requested on the Application form to the individual and review the terms and conditions section of the form with the person. Make sure each of the areas are covered in a way that assures the applicant and authorized representative, as applicable, understands the information.
3. Complete the Application form and have the applicant and authorized representative sign, as applicable.

• Process for Non-citizen: 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.
  • If the applicant is not a United States born citizen, view his/her original immigration document(s) and  scan a copy of the front and back of the presented document(s).
  • 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) to the VR Assistant Director.
  • All non-citizens will have his/her lawful presence and/or lawful authorization to work verified through the 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 completed and assessment services cannot be provided until BOTH the applicant's lawful presence and authorization for employment are 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.
• 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.

3. Release of Information form: required with appropriate signatures for all VR Applications.

4. SSDI or SSI recipient based on their disability: if needed, complete the SSA 3288 Consent for Release of Information/Earnings (VR) and the SSA 3288 Consent for Release of Information/General (VR) with appropriate signatures. 

5. ABI pre-screening question: If the applicant answered "yes" or "not sure" to the on the application to this question, 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. (See the Initial Meeting Chapter)

6. If the individual indicates he or she 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. 

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

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. 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.
• "Refused"  is an option for those who do not fit the above categories or do not wish to identify.

U.S. citizen

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

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 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, 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 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.

Medical/Health Insurance

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

• Affordable Helath 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 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.

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.

If the Applicant is working at application, the employment information can 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 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 and release,unless he or she is a minor or legally incompetent. However, it is good practice to always have the applicant sign.  
•  Authorized Representative. If the applicant is a minor or legally incompetent, the appropriate authorized representative must sign the Application and release. See VRIS Chapter: Signatures Required on VR Documents for further information.
• VR Representative. Any VR staff member may sign the Application.

• Informing prospective applicants: To assure voluntary informed choice, prospective applicants first must be provided with a VR Orientation and Initial Meeting.
• Required for transfer to the Employment Program: Before an individual in the Referral status can be transferred to the Employment Program, he or she (and if needed, his or her authorized representative) must complete and sign the VR Application and Release forms. Both forms are required to apply for vocational rehabilitation services.
• Minors: If the person is a minor, the authorized representative must sign the VR Application and Release forms. 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 and completion of the Emancipated Minor Form.
• 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 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. The effective date of the application is the date an application, which has been signed by the applicant and, if applicable, their authorized representative, is received by Nebraska VR. 

• Voter Registration: Nebraska Revised Statute §32‐310 requires Nebraska VR provide the opportunity to individuals with a disability to register to vote. 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.

 

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