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Case Services

Case Services - Application, Eligibility, Planning

Form Name Action Form Owner Revision Date Notes
Application - Spanish Print
 Angela Fujan 10/20/2023
Application - English Print
Data Entry 		Angela Fujan 10/20/2023 Updated gender 10/20/23 Updated CAP phone number. 5/16/2023 Removed Sources & Services pages 4-30-2019 Updated with TBI stuff on 12-20-2021
Communication Assessment - English Print
Data Entry 		Angela Fujan 01/24/2023
Job Planning Factors & Job Planning Discussion Order
 Angela Fujan 10/26/2021
IL Assessment-Barriers to Employment Print
 Carla Lasley 07/31/2008
IL Assessment-Household, Relocation, Cleaning Print
 Carla Lasley
IL Assessment-Menu Planning/Prep, Laundry/Clothing Care, Daycare Print
 Carla Lasley 07/31/2008
IL Assessment-Rehab Engineering & Assistive Tech Print
 Carla Lasley 07/31/2008
IL Assessment-School Needs Print
 Carla Lasley 07/31/2008
IL Assessment-Transportation, Health & Hygiene Print
 Carla Lasley 07/31/2008
IL Assessment-Work-Site Needs/Accommodations Print
 Carla Lasley 07/31/2008
Physical Capacities Print
Data Entry 		Angela Fujan 02/28/2014
Job Readiness Factors & Initial Meeting - A Guide for Staff Order
 Angela Fujan 10/26/2021
VR Psychological Narrative Report Guidelines Print
 Angela Fujan 08/31/2006
Functional Capacities Checklist Print
Order
Data Entry 		Angela Fujan 04/10/2019
Impairments Checklist Print
Order
 Angela Fujan 08/09/2019
Nebraska VR ABI Interview Data Entry Keri Bennett 05/24/2022
Career Planning Preferences - English Print
Data Entry 		Angela Fujan 01/01/2016
(TWE) Trial Work Experience Agreement Data Entry Kristi Berst 02/23/2022
Order of Selection (OOS) Questions & Answers Print
 Angela Fujan 05/08/2018
Information and Referral (I & R) to Other Programs Print
Data Entry 		Paige Rose 07/12/2022 Used for CCIR appointments, and clients on the wait list during order of selection. I and R, I & R
Guide for Approval of Eligibility and Priority Groups Print
 Angela Fujan 11/30/2017
Order of Selection (OOS) Fact Sheet Print
 Angela Fujan 10/03/2022
Order of Selection Communication to VR staff on process for working with DDD while all categories are closed Print
 Lindy Foley 06/04/2018
Order of Selection communication to VR staff on process for working with BH Regions while all categories are closed Print
 Lindy Foley 06/04/2018
Q & A on Employment Plans Print
 Carla Lasley 06/19/2018 Questions and answers are from a 6-19-18 Videoconference attended by VR staff.
Template, Background, & Instructions for Completion of Employment Plan (I/DD) Print
Data Entry 		Carla Lasley
Template, Background, Instructions for BH Employment Plan Print
 Carla Lasley 07/09/2018
Order of Selection Update for BH SE Milestones Print
 Carla Lasley 07/18/2018 updated per DHHS
VR Referral Form - English Print
Data Entry 		Angela Fujan 10/20/2023
Key VR Time Frames Print
 Angela Fujan 01/02/2019
Signing of VR Documents chart Print
 Carla Lasley 04/02/2019
Initial Meeting Questions Print
 Angela Fujan 08/01/2019
Impediment Questions Print
 Angela Fujan 04/04/2019
Summary of Initial Meeting Print
Data Entry 		Angela Fujan 04/04/2019
Summary of Initial Meeting-Spanish Print
Data Entry 		Angela Fujan 04/04/2019
Information and Referral (I & R) to Other Programs - Spanish Print
Data Entry 		Paige Rose 07/12/2022 I and R, I & R,
Order of Selection Job Retention Questions Print
Data Entry 		Angela Fujan 03/31/2019
Order of Selection (OOS) Fact Sheet Spanish Print
 Angela Fujan 10/03/2022
VR Process Chart Angela Fujan 10/26/2021
Initial Meeting to Next Step Guide Print
 Angela Fujan 03/31/2021
Clients Removed from Wait List Who are Working Print
 Paige Rose 02/25/2020
Client User ID Password Letter Print
 Cathy Callaway 07/15/2021
On-Line Access to Pay Stub - English Print
 Cathy Callaway 10/29/2024
On-line Access to Pay Stub - Spanish Print
 Cathy Callaway 10/29/2024
Career Planning Preferences - Spanish Print
Data Entry 		Angela Fujan 04/15/2020
VR Referral Form - Spanish Print
Data Entry 		Angela Fujan 10/20/2023
OOS Upgrading Priority Group Letter - English Print
 Angela Fujan 08/04/2021
AbilityOne Process Data Entry Paige Rose 04/01/2022
OOS Upgrading Priority Group Letter - Spanish Print
 Angela Fujan 08/27/2021
Progressive Employment Model Mary Matusiak 03/31/2022
Substance Use Disorders- VR Desk Reference Print
 Angela Fujan 11/18/2022 Rehabilitation Research and Training Center on Substance Abuse, Disability and Employment
Communication Assessment - Spanish Print
Data Entry 		Angela Fujan 01/24/2023
List of Background Checks Carla Lasley 01/05/2024
Functional Cognitive Assessment Referral Data Entry Keri Bennett 10/29/2024

Case Services - Case, Caseload Management

Form Name Action Form Owner Revision Date Notes
Action Planner Order
 Angela Fujan 08/31/2011
Appointment Reminder Postcard Order
 Sarah Chapin 05/20/2014
Assignment Purchases-Medicare Print
 Cathy Callaway Must open this document in Excel
Assignment Purchases-Third Party Print
 Cathy Callaway This document must be opened in Excel
Blank Memo Post Card Order
 Sarah Chapin
Case File Order List Print
 Angela Fujan 06/04/1919
Client Reimbursement Print
 Cathy Callaway 04/30/2019
Acceptance Agreement Form (Equipment Agreement) Print
Data Entry 		Mary Matusiak 02/28/2021
High Cost Request Print
Data Entry 		Angela Fujan 09/24/2019
Next Steps - English Order
 Angela Fujan 11/30/2010
Proof of Purchase Print
Data Entry 		Cathy Callaway 04/30/2019
Suicide Call Print
Data Entry 		Holly Enriquez 02/28/2009
Provider Invoice Print
Data Entry 		Cathy Callaway 02/28/2013
Next Steps- Spanish Print
 Angela Fujan 11/30/2015
Purchase of Goods and Services Print
 Angela Fujan 05/01/2017
Key VR Time Frames Print
 Angela Fujan 01/02/2019
Exit Status Decision Tree Print
 Paige Rose
Electronic Case File Categories/Attachment Types Cathy Callaway 04/01/2024
A Guide for Supporting Individuals With Developmental Disabilities In The Workplace Print
 Cathy Callaway 11/01/2010 This was content saved from the old VRIS>
Case File Request for Information Print
Data Entry 		Cathy Callaway 04/13/2023
Medicaid Spreadsheet (No Insurance) Data Entry Amy Hancock
Medicaid Spreadsheet (With Insurance) Data Entry Amy Hancock
Case Review - Compliance (Draft) Holly Enriquez 06/30/2024
Case Review - Quality (Draft) Holly Enriquez 06/30/2024

Case Services - IPE

Form Name Action Form Owner Revision Date Notes
Corrective Action Plan Print
Data Entry 		Cathy Callaway 04/30/2019
IPE Guide Print
 Angela Fujan 08/30/2019
Assessment for Competitive Integrated Employment Determination Checklist Print
Data Entry 		Kristi Berst 04/01/2024
Individualized Plan for Employment (IPE) - English Data Entry Cathy Callaway 07/01/2023
IPE Services Data Entry Cathy Callaway 04/08/2022
Assessment Services Cathy Callaway 04/08/2022
Assessment Supports Cathy Callaway 07/01/2023
Individualized Plan for Employment (IPE) - Spanish Cathy Callaway 07/06/2023
State VR SSA Coordinators Carla Lasley 07/07/2022
Discovery Activity: Work Values - English Data Entry Angela Fujan 05/11/2023
Discovery Activity: Work Values - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Preferences - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Preferences - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Interests - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Interests - English Angela Fujan 05/11/2023
Discovery Activity: Work Considerations - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Considerations - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Non-Paid Work Experiences - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Non-Paid Work Experiences - English Angela Fujan 05/11/2023
Discovery Activity: Make Sure - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Make Sure - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Job Skills - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Job Skills - English Angela Fujan 05/11/2023
Discovery Activity: Family Support Network - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Family Support Network - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Application for Employment - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Application for Employment - Spanish Print
Data Entry 		Angela Fujan 05/11/2023

Case Services - Letters

Form Name Action Form Owner Revision Date Notes
15 Day Letter - English Print
 Angela Fujan 02/14/2020
Office Director Letter Print
 Angela Fujan 10/07/2022
Successful Outcome Letter (Non SSA) in English Print
 Angela Fujan 10/07/2022
Termination Letter for Non SSA Recipients in English Print
 Angela Fujan 10/07/2022
Welcome Letter with Link to Orientation Video-Constant Contact Sarah Chapin 07/10/2024
Schedule A Certification Letter for VR Staff Print
 Mary Matusiak 10/01/2018
Pre-Employment Transition Services Work Based Learning Letter-Paid Print
Data Entry 		Lupe Stevens 08/30/2017
Pre-Employment Transition Services Work Based Learning Letter-Unpaid Print
Data Entry 		Lupe Stevens 08/30/2017
Section 511: Employment Not Expected from Services Letter Paige Rose 09/08/2020
Pre-Employment Transition Services Non Participation Letter - English Print
 Lupe Stevens 12/19/2019
Pre-Employment Transition Services Welcome Letter - English Print
 Lupe Stevens 10/20/2017
Pre-Employment Transition Services Welcome Letter - Spanish Print
 Lupe Stevens 10/20/2017
Order of Selection Retention Letter Print
 Angela Fujan 11/19/2020 Example of Retention letter sent out from State Office
OOS Off Wait List Letter - English Print
 Angela Fujan 02/25/2020 Example of Off Wait List letter sent out by State Office
Orientation Welcome Letter-Word version Print
 Sarah Chapin 12/14/2017
Eligibility Letter - English Angela Fujan 07/01/2024 Example of Adult waiting list letter sent out by State Office
OOS Upgrading Priority Group Letter - English Print
 Angela Fujan 08/04/2021
Contact Letter - English Print
 Angela Fujan 04/17/2019
Pre-Employment Transition Services Termination after Graduation Letter - English Print
 Lupe Stevens 08/02/2019
Successful Outcome Letter (Non SSA) in Spanish Print
 Angela Fujan 10/07/2022
Pre-Employment Transition Services Termination after Graduation Letter - Spanish Print
 Lupe Stevens 04/03/2020
Termination Letter for SSA Recipients in English Print
 Carla Lasley 10/07/2022
Successful Outcome Letter (SS beneficiaries) in English Print
 Carla Lasley 10/07/2022
Termination Letter for SSA Recipients in Spanish Print
 Carla Lasley 10/07/2022
Successful Outcome Letter (SS beneficiaries) in Spanish Print
 Carla Lasley 10/07/2022
OOS Upgrading Priority Group Letter - Spanish Print
 Angela Fujan 08/27/2021
OJT Letter Print
Data Entry 		Mary Matusiak 01/12/2022
Contact Letter - Spanish Print
 Angela Fujan 04/25/2022
15 Day Letter - Spanish Angela Fujan 05/11/2022
Pre-Employment Transition Services Non Participation Letter - Spanish Lupe Stevens 09/02/2022
Termination Letter for Non SSA Recipients in Spanish Angela Fujan 10/12/2022
Eligibility Letter - Spanish Print
 Angela Fujan 05/07/2020
OOS Off Wait List Letter - Spanish Print
 Angela Fujan 11/18/2022

Case Services - OJE, OJT, Payroll, Placement

Form Name Action Form Owner Revision Date Notes
Direct Deposit Enrollment Print
Data Entry 		Cinda Wacker 07/31/2013
Job Facts Guide Print
Order
 Mary Matusiak 05/31/2014 Job Facts Guide is available as a fillable pdf.
Job Search Agreement and Consent - English Print
Order
Data Entry 		Mary Matusiak 03/16/2023
Job Search Agreement and Consent - Spanish Print
Data Entry 		Mary Matusiak 03/16/2023
Job Seeking Skills Training Application Print
Data Entry 		Mary Matusiak
Job Seeking Skills Training Booklet - English Order
 Mary Matusiak 12/01/2017
I-9 Checklist Print
 Holly Enriquez
I-9 Form & Information Print
 Amy Hancock 03/06/2024 Amy Hancock provided this update on 10-31-23
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 03/06/2024
Weekly Job Search Record Print
Order
Data Entry 		Mary Matusiak
Work Opportunity Tax Credits - 9061 Individual Characteristics - English Print
 Mary Matusiak
Work Opportunity Tax Credits - 9061 Individual Characteristics - Spanish Print
 Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - English Print
 Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - Spanish Print
 Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Print
 Mary Matusiak
On-the-Job Report Print
Data Entry 		Kristi Berst 07/01/2020 Replaces the OJT Training Progress Report and OJE Evaluation Report
Volunteer/Non-Paid Accident Coverage Holly Enriquez 08/07/2024 This form confirms that the State of Nebraska Vocational Rehabilitation has insurance in place for all registered volunteers and participants as outlined.
Request for Certificate of Self-Insurance Print
 Holly Enriquez 07/01/2024
Focus Card Enrollment Form Print
Data Entry 		Amy Hancock 07/05/2023
Request Temporary Access Print
 Holly Enriquez 06/06/2022
Time Conversion Chart Print
 Cathy Callaway
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 07/05/2023
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 12/13/2023
OJE/TWE Checklist Print
Data Entry 		Kristi Berst 02/25/2022
OJE/TWE Timesheet Print
Data Entry 		Kristi Berst 01/12/2022
OJE/TWE Consent Print
Data Entry 		Kristi Berst 01/12/2022
Optional Invoice for Providers WSST/Job Coaching 7/23 Amy Hancock 11/20/2023
Pearls of Placement Reference Guide Mary Matusiak 01/24/2024
Employment Success Skills Mary Matusiak 10/09/2024

Case Services - Post Secondary

Form Name Action Form Owner Revision Date Notes
Budget Worksheet-Post-Secondary Print
 Angela Fujan 05/31/2006
Budget Worksheet-Education Financial Aid Print
 Angela Fujan 03/02/2016
Financial Aid Budget Information Print
 Angela Fujan 02/03/2011
Post Secondary Training Justification - Word doc Print
Data Entry 		Angela Fujan 09/30/2010
Post Secondary Training Justification - PDF Print
Data Entry 		Angela Fujan 09/30/2010
Student Financial Aid Report (SFAR-E) Data Entry Angela Fujan 08/14/2024
VR Financial Aid Data Entry Angela Fujan 11/10/2022
Informational Interview Questionnaire Data Entry Paige Rose 11/20/2018

Case Services - Release, Consent, Referral

Form Name Action Form Owner Revision Date Notes
NE VR Sign Language Interpreting Request Print
Order
 Vicki Steinhaur-Campbell 05/05/2016
VR Referral Form - English Print
Data Entry 		Angela Fujan 10/20/2023
Release of Information English Print
Data Entry 		Angela Fujan 02/13/2024
Request for Medical Information - English Print
Data Entry 		Angela Fujan 04/01/2019
Emancipated Minor Form Print
 Carla Lasley 04/02/2019
Self Employment Feasibility Referral Form Print
Data Entry 		Julie Shively 05/23/2022
Agrability Referral Print
Data Entry 		Angela Fujan 03/31/2014
ATP/VR Referral Print
Data Entry 		Nancy Noha 03/27/2024
BP/DHHS Authorization for the Disclosure of Protected Health Information Print
Data Entry 		Carla Lasley 01/22/2020
Authorization for Exchange of Information-Multi Agency Release Print
 Carla Lasley 04/30/2019
Benefits Orientation/Referral for Benefits Services Print
Data Entry 		Carla Lasley 04/12/2024
Maximus: Notification To Take Ticket Out of Assignment Print
Data Entry 		Carla Lasley 09/30/2012
Mediation Referral Print
 Angela Fujan 04/30/2019
Service & Device Application - English Print
 Nancy Noha 10/20/2023 Multi-Agency Form
Vocational Evaluation Referral Print
 Paige Rose 12/08/2022
Video & Media Information Release (Client) Print
Data Entry 		Sarah Chapin 04/30/2019 Release of Information, Media Release, Consent for Media
Pre-Employment Transition Services Consent & Information Release - English Print
Data Entry 		Lupe Stevens 05/16/2023
Pre-Employment Transition Services Consent & Information Release - Spanish Print
Data Entry 		Lupe Stevens 05/16/2023
Section 511: Refusal of Pre-Employment Transition Services (While still in High School) Data Entry Paige Rose 11/30/2020
ATP-CPAP Facility Assessment Referral Form Print
Data Entry 		Nancy Noha 07/18/2017 For BAM and CPAP staff use with businesses
Pre-ETS Job Exploration Referral Data Entry Paige Rose 01/24/2023
Benefits Provider Choice or Declination - English Print
 Carla Lasley 08/23/2024
BP/DHHS Authorization for the Disclosure of Protected Health Information-Spanish Print
Data Entry 		Carla Lasley 01/22/2020
VR Referral Form - English Print
Data Entry 		Angela Fujan 10/20/2023
Title II: Social Security Disability Insurance Work Incentives Guide 2023 - English Print
 Carla Lasley 01/30/2023
Title XVI: Supplemental Security Income Work Incentive Guide 2023 - English Print
 Carla Lasley 01/30/2023
Background Screen Release of Information (Disclosure and Authorization Form) Print
 Mary Matusiak
Pre-Employment Transition Services Release of Information English Print
Data Entry 		Lupe Stevens 04/29/2020
Release of Information Spanish Print
Data Entry 		Angela Fujan 02/13/2024
Request for Medical Information - Spanish Print
Data Entry 		Angela Fujan 04/01/2019
VR Referral Form - Spanish Print
Data Entry 		Angela Fujan 10/20/2023
Pre-Employment Transition Services Release of Information Spanish Print
Data Entry 		Lupe Stevens 04/30/2020
Benefits Provider Choice or Declination - Spanish Print
Data Entry 		Carla Lasley 08/23/2024
Title XVI: Supplemental Security Income Work Incentive Guide 2023 - Spanish Print
 Carla Lasley 07/19/2023
Service & Device Application - Spanish Print
 Nancy Noha 10/20/2023
BP/SSA 3288 Consent for Release of Information - General English Data Entry Carla Lasley 11/10/2021
BP/SSA 3288 Consent for Release of Information - General Spanish Print
Order
 Carla Lasley 11/10/2021
VR/SSA 3288 Consent for Release of Information - General English Print
Data Entry 		Carla Lasley 11/10/2021
VR/SSA 3288 Consent for Release of Information - General Spanish Print
Data Entry 		Carla Lasley 11/10/2021
Title II: Social Security Disability Insurance Work Incentives Guide 2024 - English Data Entry Carla Lasley 12/26/2023
Title II: Social Security Disability Insurance Work Incentives Guide 2024 - Spanish Print
Data Entry 		Carla Lasley 12/26/2023
Title XVI: Supplemental Security Income Work Incentives Guide 2024 - English Print
 Carla Lasley 03/25/2024
Title XVI: Supplemental Security Income Work Incentives Guide 2024 - Spanish Print
 Carla Lasley 03/25/2024
Concurrent Work Incentives Guide 2023 - English Print
 Carla Lasley 01/30/2023
Concurrent Work Incentives Guide 2023 - Spanish Print
 Carla Lasley 07/19/2023
Guide for Nebraska VR Staff Requesting Information from NE Department of Correctional Services Holly Enriquez 08/25/2022
Title II: Social Security Disability Insurance Work Incentives Guide 2023 - Spanish Print
 Carla Lasley 01/30/2023
Concurrent Work Incentives Guide 2024 - English Carla Lasley 03/25/2024
Concurrent Work Incentives Guide 2024 - Spanish Carla Lasley 03/25/2024

CPAP 2.0

Form Name Action Form Owner Revision Date Notes
CPAP 2.0 Individualized Business Plan (IBP) Print
Data Entry 		Mary Kunes-Neary 08/16/2022

Section 511

Form Name Action Form Owner Revision Date Notes
Section 511: Refusal of Pre-Employment Transition Services (While still in High School) Data Entry Paige Rose 11/30/2020
Section 511: Refusal to Participate - English Data Entry Paige Rose 01/27/2023
Section 511: Documentation Checklist for Adults (age 25 and older) Data Entry Paige Rose 02/24/2020
Section 511: Documentation Checklist for Youth (Age 24 and younger) Print
Data Entry 		Paige Rose 02/24/2020
Section 511: Discovery Payment Schedule Print
 Paige Rose 11/27/2018
Information and Referral (I & R) to Other Programs Print
Data Entry 		Paige Rose 07/12/2022 Used for CCIR appointments, and clients on the wait list during order of selection. I and R, I & R
Section 511 Decision Tree Print
 Paige Rose 07/07/2020
Information and Referral (I & R) to Other Programs - Spanish Print
Data Entry 		Paige Rose 07/12/2022 I and R, I & R,
Section 511 Decision Tree for Staff Only Print
 Paige Rose 07/07/2020
Section 511: CCIR Case Review Checklist Print
Data Entry 		Paige Rose 01/24/2023
Section 511: Refusal to Participate - Spanish Data Entry Paige Rose 01/27/2023

Self Employment-Planning

Form Name Action Form Owner Revision Date Notes
Self Employment Discussion Questionnaire-Data Entry Print
Data Entry 		Julie Shively 03/24/2021 Use this Word version to allow for expanding data entry. Tab between fields.
Self Employment Rates & Hourly Estimates Print
 Mary Matusiak 05/25/2023
Self Employment Personal Finance Worksheet Print
Data Entry 		Julie Shively 02/07/2017
Self Employment-Advantages Print
 Julie Shively 03/01/2017
Self-Employment - Green Flags/Red Flags Print
 Julie Shively 12/10/2021
Self Employment Feasibility Referral Form Print
Data Entry 		Julie Shively 05/23/2022
Self Employment Process Chart Print
 Julie Shively 01/26/2018
Supported Self-Employment Guidance Print
 Mary Matusiak 05/23/2018
Sources & Uses of Funds Print
Data Entry 		Julie Shively 04/09/2021
Viability Referral Data Entry Angela Fujan 06/14/2021 Download form to open in Word.

Supported/Customized Employment

Form Name Action Form Owner Revision Date Notes
VR Profile for Supported or Customized Employment Data Entry Paige Rose 04/30/2019
Section 511: Discovery Payment Schedule Print
 Paige Rose 11/27/2018
Supported Self-Employment Guidance Print
 Mary Matusiak 05/23/2018
ABI/Autism SE Supplemental Questionnaire Print
Data Entry 		Carla Lasley 11/30/2018
AbilityOne Process Data Entry Paige Rose 04/01/2022
Supported and Customized Employment Referral Data Entry DJ Plautz 07/01/2023 New form as of 7/1/2023/
Supported and Customized Employment Plan for Job Development - Outcome Report & Invoice Data Entry DJ Plautz 09/01/2023 New as of 7/1/2023
Supported and Customized Employment Job Search and Placement - Outcome Report & Invoice Data Entry DJ Plautz 09/01/2023
Supported and Customized Employment Monthly Report Data Entry DJ Plautz 07/01/2023
Supported and Customized Employment Job Stability Report Data Entry DJ Plautz 07/01/2023 Active 7/1/2023
Supported and Customized Employment Extended Services for Youth Report & Invoice Data Entry DJ Plautz 09/20/2023 Active on 7/1/2023, updated on 9/29.
Supported and Customized Employment Job Coaching/Job Support Report & Invoice Data Entry DJ Plautz 09/01/2023 Active on 7/1/2023. Updated in 9/25.
Supported and Customized Employment Verification of Employee Hours Worked Data Entry DJ Plautz 09/01/2023
Supported and Customized Employment - Side by Side Referral Decision Guide DJ Plautz 07/01/2023 Provided by the Vocational Rehabilitation Technical Assistance Center for Quality Employment (VRTAC-QE) . tacqe.com
Supported and Customized Employment Fiscal Chart Print
 DJ Plautz 11/22/2023
Supported and Customized Employment Provider Handbook Print
 DJ Plautz 11/22/2023
Supported/Customized Employment Payment Schedule DJ Plautz 07/01/2024

Pre-Employment Transition Services

Work Based Learning

Form Name Action Form Owner Revision Date Notes
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Work-Based Learning Experience Information Lindsay Brown 05/05/2022
Work-Based Learning Experience (WBLE) Timesheet Print
Data Entry 		Lindsay Brown 06/13/2023 work-based
Pre-Employment Transition Services Work-Based Learning Experience Report Print
Data Entry 		Lupe Stevens 06/20/2019
Pre-Employment Transition Services Work-Based Learning Experience (WBLE) Checklist Print
Data Entry 		Lupe Stevens 08/29/2023
Pre-Employment Transition Services Consent for a Non-paid Work Based Learning Experience Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Spanish Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Spanish Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Work-Based Learning Experience Information Spanish Lindsay Brown 05/04/2022
Pre-Employment Transition Services Consent & Information Release - English Print
Data Entry 		Lupe Stevens 05/16/2023
Pre-Employment Transition Services Consent & Information Release - Spanish Print
Data Entry 		Lupe Stevens 05/16/2023
Pre-Employment Transition Services Consent for Non-paid Work Based Learning Experience Spanish Print
Data Entry 		Lupe Stevens 04/30/2019
Nebraska VR/SPED Inter-Departmental Agreement Print
 Lindy Foley 08/22/2018 Inter-departmental agreement between Nebraska VR and the Office of Special Education (SPED)
Signing of VR Documents chart Print
 Carla Lasley 04/02/2019
Pre-Employment Transition Services Release of Information English Print
Data Entry 		Lupe Stevens 04/29/2020
Pre-Employment Transition Services Release of Information Spanish Print
Data Entry 		Lupe Stevens 04/30/2020
Transition Services Partnership Planner Lupe Stevens 08/16/2021
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 03/06/2024
I-9 Form & Information Print
 Amy Hancock 03/06/2024 Amy Hancock provided this update on 10-31-23
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 07/05/2023
On-Line Access to Pay Stub - English Print
 Cathy Callaway 10/29/2024
Class Work Site Observation Checklist Print
Data Entry 		Paige Rose 04/02/2021
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 12/13/2023
Optional Invoice for Providers WSST/Job Coaching 7/23 Amy Hancock 11/20/2023

Administrative

Administrative - NDE

Form Name Action Form Owner Revision Date Notes
Volunteer/Unpaid Intern Print
 Holly Enriquez This form is housed on Inside NDE.
Contracts, Letter Contracts, Purchasing Procedures Cathy Callaway
Direct Deposit Enrollment Print
Data Entry 		Cinda Wacker 07/31/2013
Horizontal Wage Progression Holly Enriquez Contact NDE HR for this form.
I-9 Checklist Print
 Holly Enriquez
I-9 Form & Information Print
 Amy Hancock 03/06/2024 Amy Hancock provided this update on 10-31-23
Merit Stipend Request Holly Enriquez Contact NDE HR for this form
Work Schedule Print
 Holly Enriquez
SOS Personnel Request form (Will download to your Downloads folder) Print
Data Entry 		Holly Enriquez
Focus Card Enrollment Form Print
Data Entry 		Amy Hancock 07/05/2023
ADA Guidance Print
 Holly Enriquez 02/24/2017
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Print
 Mary Matusiak
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 12/13/2023

Administrative - Nebraska VR

Form Name Action Form Owner Revision Date Notes
Confidentiality Agreement Print
 Holly Enriquez 07/27/2021
Incident/Accident/Injury Report for Clients & Applicants Print
Data Entry 		Holly Enriquez 02/08/2023
Direct Purchase Authorization (DPA) Print
Data Entry 		Cathy Callaway
Employee Roster Information Print
Data Entry 		Holly Enriquez 05/03/2017
Position Information Sheet Associate Print
Data Entry 		Holly Enriquez 10/25/2019
Position Information Sheet Service/Rehab Specialists Print
Data Entry 		Holly Enriquez 10/25/2019
Supported Employment Case Review DJ Plautz 07/01/2024
Service Agreement Data Entry DJ Plautz 01/08/2024
Training Request Print
Data Entry 		Ken Cuevas 02/18/2020
TSB Log Print
 Melysa Johnson
Video & Media Information Release (Client) Print
Data Entry 		Sarah Chapin 04/30/2019 Release of Information, Media Release, Consent for Media
Video Conference Participant List Print
 Paige Rose 11/09/2018
I-9 Checklist Print
 Holly Enriquez
State Vehicle Waiver - VR English and Spanish Print
 Holly Enriquez 06/04/2019 English and Spanish waiver
VR Vendor Office Listing Print
 Cathy Callaway 12/31/2012
Suicide Call Form Print
Data Entry 		Holly Enriquez 12/16/2015
Code of Conduct Print
Data Entry 		Angela Fujan 02/01/2021
Summary of Case Review Findings Print
Data Entry 		Angela Fujan 01/13/2020
Transition Partnership Planning Form Data Entry Lupe Stevens 08/17/2021 Link to web form for the Transition Services Partnership Planner - Guide for Educators
Training Plan Data Entry Ken Cuevas 09/19/2018
18/23 Month Assessment Action Plan Print
Data Entry 		Holly Enriquez 09/05/2018
Order of Selection (OOS) Talking Points Print
Data Entry 		Lindy Foley 05/03/2018
Nebraska VR/SPED Inter-Departmental Agreement Print
 Lindy Foley 08/22/2018 Inter-departmental agreement between Nebraska VR and the Office of Special Education (SPED)
NCBVI and Nebraska VR MOU Print
 Angela Fujan
Continuity of Operations Plan (COOP) for COVID-19 Print
 Lindy Foley 08/26/2021
Nebraska VR Question and Answers Continuity of Operations Plan (COOP)- COVID 19 Print
 Lindy Foley 04/01/2021
Fax Log Print
Data Entry 		Tibor Moldovan 05/01/2020
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 12/13/2023
External Agency/Business Partner Media Release Data Entry Mary Matusiak 03/16/2022
Request Temporary Access Print
 Holly Enriquez 06/06/2022
Compliance Review (Download Word Document) Cathy Callaway 06/12/2024
Quality Review (Download Word Document) Cathy Callaway 06/12/2024

Administrative - State of Nebraska

Form Name Action Form Owner Revision Date Notes
Voter Registration Form English Print
Data Entry 		Holly Enriquez 06/24/2024
Tax Exempt Form (Form 13) Print
 Cathy Callaway 07/17/2024 Office Listing is included with the form
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 03/06/2024
W-9 & ACH Enrollment Print
Data Entry 		Cinda Wacker
CSI Exception Request Print
Data Entry 		Holly Enriquez 09/23/2024
Voter Registration Form Spanish Print
Data Entry 		Holly Enriquez 06/24/2024
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 07/05/2023
Voter Registration Disclaimer Print
 Holly Enriquez 04/01/2020
Voter Registration Disclaimer-Spanish Print
 Holly Enriquez 04/14/2020
Records Transfer Sheet Print
 Holly Enriquez 04/06/2023

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